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Apppcstlons WM N IS,am eed When Submitled property Completed Be Swe To Sign The AppSeatlon. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGR U!"ANDMR APPLICATION IF VEHICLE INVOLVED.GIVE <br /> AFPLrCAN•a ANOMPMake <br /> coNTPACTMANDION ENVIRONMENTAL HEALTH PERMIT/SERVICES Lid No <br /> PROKM AMNOII FM!it'SSllftlteEl M NOUN Regist-No. <br /> F&OLSTMT wN 11M(STATE 1111vernm Color <br /> NIAAMM reelM■AMCMEs Ails 9EMM9S <br /> NM11lICES <br /> rApplication Date 7-22-•86 Business/Name To Appear On Permit <br /> Type Permli/Service Requested. xerox co ie <br /> Appllc.rlt Name <br /> Christopher Hol Address B21 <br /> _Business Telephone No. Emergency Telephone No. <br /> property Location/Address <br /> �pr g owner Address <br /> L Operators Name Address <br /> 1, FOOD VATABLISHMENTS Total Building Sq.Footage Restaurant,Marcimurn Seating Capacity <br /> CI RESTAURANT E3FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE (3MEAT MARKET � <br /> 13 FOOD PROCESSING POINT 13 COMMISSARY © ICE PLANT ❑ BAKERY <br /> O ROADSIDE FOOD STAND. (3 t..IOUOR STORE 13 BAR ITINERANT RESTAURANT <br /> 13 CONFECTIONARY STORE 17 FOOD SALVAGER d FOOD DEMONSTRATION 0 FOOD VENDOR <br /> ❑ VENDING MACHINESINO.of ❑ MOBILE FOOD PREP.UNIT 0 VENDING VEHICLE <br /> 13 FOOD CfIOP HARVESTING/No-Of Field Employees <br /> ALL APPLICANTS: Total Empbysas Including Operators <br /> _' HO1JSM ❑ CERTIFICATE OF OCCUPANCY <br /> 0 HOTEUMOTEUMa.of Unita <br /> 0 MOBILE HOME PARK/NM of SPacss <br /> & WATER QUALITY 13 WATER SAMPLE(BactsdA • ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> No.OF PUBLIC SERVED(Cor"W60ns) <br /> -s. RECREAT'101i AL HEALTH 13 SWIMMING POOL © SPA 0 WADING POOL 13 NATURAL BATHING PUKE <br /> L VKCTOr1 CONTROL ❑ POULTRY FARM/Mazirimurn NO.of Birds <br /> D KENNEL/R,x„r,eye /Animal Poputation No. No.of Confining Capes <br /> sewage Disposal Maly <br /> Said Waste D"Method <br /> wow Supply Source AnMrIa)Waste Disposal Method ' <br /> BUSINESS LICENSE <br /> L © CONSULTATION FEE 0 <br /> T. 13 PLAN CHECKING FEE I3 DANCE pEAMIT <br /> �. REAL"LATE r <br /> REOUEST: Wstar Well Inpactionl3 SmpleO TRIS Company <br /> Sewage System Inspection 13 Address <br /> Tow No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name t <br /> Service Request For Dab _ <br /> I hereby certify that I haw prepared this application and that the work will be dons In accordance with San Jeaquk+County <br /> ordinances.state laws,and mica and regulations of the San Joaquin Local Health District. <br /> APPLICANT`S SIGNATURE X TW* Date <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> ar <br /> Fee b DueD;aW tv. O ectND O Ena © rr.rr <br /> 111".L.1000 REMMANCE <br /> tLSExPAATIOPATE ATE i� ❑tesa reMs + <br /> AwoifT DU CHEcxW <br /> NREMITTED A <br /> UNT <br /> FEE $10.00 @$10./hr Search, eview, ca <br /> LESS <br /> PRONATION I <br /> PLUS <br /> PENALTY <br /> OTNEIt + <br /> OTHM 2.09 Postage I $17.56 <br /> a <br /> e <br /> Recefted by DO* fwcov No. M.nM No Saauance DOM M.rad <br /> APTLW-UfT—arn AAALL-Z0"=TQ &"M0MMtxTAL SCALY"KftWff411tvbC[11 7Mt L MAZILTOM AII@�.PM-Ma=0 aToC T09k CA WN <br />