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i <br /> AppilcalMIll 9 80 P+oeratsaO When SubeRMd Propel Completed.13 <br /> plete0 Sum T qn Ti ApP�at� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GEN€M _ <br /> vee* 110M^NDi APPLICATION M " 1`1fOLrm'atrE <br /> � ,s ANDOC1t Maks <br /> CAXJTRACTOR AND/CA ENVIRONMENTAL HEALTH PERMIT/SERVICES U4 � <br /> BROKE"AMC" iM/fSt"umofAY'S,Msel111S Regiat No. <br /> twsul:Felts wATIM SAwrlltlS <br /> t$TRA'nM Ka IATATf t SPNTNN Coto. J <br /> NUMSEX I*eIIITST WCUSS ASS[flCll" <br /> M"KELLAX190 an"Cla <br /> rAppllcallon Date 7-22-86 BusineswWame To Appear On Permit <br /> Typo Permit/Ser Ace Requested: Xe ro -copies2 �� <br /> Applicant Name Christopher Hol Address <br /> Emergency Telephone No. <br /> Business Telephone No. fl MY ' <br /> Property LocatloWAddress <br /> Property Owner <br /> Address <br /> wn <br /> L Operai Nems Address <br /> 1. FOOD VITABLISHMENTS Total Building Sq.Footage Restaurant.Maximum Selling CapaCity i <br /> 13 RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ mEAT <br /> E3 BAKERY <br /> 13 FOOD PROCESSING PLANT 13 COMMISSARY 13 ICE PLANT <br /> ❑ ROADSIDE FOOD STAND• ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE (3 FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MIACHINEW40.at ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVE=NIG/No.of Field Employea's . <br /> ALL APPLICANTS: Tota!Empbysos Including OPaMOM <br /> Z HOLD <br /> ❑ <br /> E3 HO d UnMS CERTIFICATE OF OCCUPANCY <br /> ❑ mMLE HOME PARIVND.of SPaces <br /> i, WATER QtJAll ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Conn.octions) <br /> dill IIECREATI011 HEALTH ❑ SWIMMING POOL ❑ SPA ❑ wAD1NG POOL ❑ NATURAL BATHING PLACE 1 <br /> S. VECTOII CONTROL ❑ POULTRY FARLVMLxirnum No.of Birds ' <br /> E3KENINBJRunwaya---�--/Animal Populat'On No. No.d Confining Capel <br /> Sewage oh poaal Method <br /> Solid wasts Dispolal Method <br /> water Supply Souron Animal waste Disposal Method <br /> S. CI CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE'PERmrr <br /> S. REAL ESTATE <br /> REOUF.IST: WSW Well lrrpactlon❑ Sampls❑ Title Company Te>e. <br /> Sows"System Inspection ❑ Address <br /> Escrow No. <br /> Seiler Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For pate _ <br /> I hereby certify that i have prepared this appliaatkxl and that the work vAll be done in accondani vdtht San Joaquin County <br /> ordinaross,state laws.and ruses and regulations of the San Joaquin Local Health District <br /> APPLICANTS SIGNATURE X Title Date <br /> LI <br /> FOR DEPARTMENT USE ONLY <br /> Pee b JDuK❑,aL�tLV.- - ❑tf".0 n 01'6"sm': .❑EAc34 13Jrlury 1 a Pwoom a-er.t.rrr�/y a1. . ❑�ruiv 1• Of�r 31 <br /> . R6>warr <br /> SASE E%Pl/1NATtON trgLSr1O REUi11TANCE i ALp�rT DUi CH <br /> DATE DATE REMITTED AAaO4JNT <br /> F $10.00 010./hr Search, review, cap <br /> LM <br /> PRORATMN <br /> PLUS <br /> F"ALTT <br /> on+ER i <br /> OTHM 2.09 Postage $17.56 <br /> 6 ' <br /> R cei"O by Dap A&Q*%K No Pw.n.1 NO. reWa++u Dat• ala"d Dofte"d r <br /> APPLACAMT—rlCninaLA-0112 A M "ViaOM O1TAL"LILLT11 Pn;IMlrTla=ai 1401 L NAMTON A1rf►A.a"MO STOC=TOK CA easel <br />