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APPUCOUNO WIN SAIL Wh*n'Submitted Property Completed. 111*41WIgn The Applicallom <br />SAN JOAQUIN LOCAL NFALTH DISTRICT GENERAL <br />APIPUCATION IF VEHICLE INVOLVED, OWE <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES Msk* <br />Lid. NO. <br />FM 111111TAKOWN1111% NOUSM <br />now pe" WAM smem Regist. No. <br />KA UTATE ospaTon color <br />FMM BANC= An KIANM <br />lr4l 4 / / 4 If t <br />141ilit", <br />2 .0 FW 0 IWA. <br />91FIR <br />property Owner Address <br />L Operator's Name—F <br />ijf,"k"rrkQ1AL4L- - -Address-!Y/m N BEksaNK �f <br />1. FOOD UTABLISHMENTS Total Building Sq. Footage Restaurant. Maximum Sealing CA�aclty <br />• RESTAURANT 13 FOOD MARKET RETAIL 13 FOOD MARKET WHOLESALE 0 MEAT MARKET <br />• FOOD PROCESSING PLANT 13 COMMISSARY E■3 ICE PLA14T 1■ <br />3 BAKERY <br />• ROADSIDE FOObSTAND. 13 LIOUOR STORE E3 BAR 1■ <br />3 ITINERANT RESTAURANT <br />• CONFECTIONARY STORE 0 FOOD SALVAGER 0 FOOD DEMONSTRATION 13 FOOD VENDOR <br />• VENDING MACHINESINo. of 13 MOBILE FOOD PREP. UNIT 0 VENDING VEHICLE <br />0 FOOD CROP HARVESTING/No. of Field Err�Ployeft <br />ALL APPLICANTS. Total Employees Including Operators <br />2. HOUSING <br />0 HOTEL/MOTELMO. of Units 13 CERTIFICATE OF OCCUPANCY <br />0 MOBILE HOME PARK/No. of Spaces <br />& WATER QUALITY 0 WATER SAMPLE (Bacterial) E3 CHEMICAL <br />13 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 13 WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIO14AL HEALTH El SWIMMING POOL 13 SPA 13 WADING POOL 13 NATURAL BATHING PLACE <br />S. VECTOIII CONTROL 13 POULTRY FARM/Maxlmum No. of Birds <br />G KENNEL/Runwap — /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />0�114r M. <br />- J7 <br />Water Supply Source Animal Waste Disposal Method <br />& E3 CONSULTATION FEE 13 BUSINESS LICENSE <br />7. M PLAN CHECKING FEE 13 DANCE PERMIT <br />oL REAL ESTATE r <br />REQUEST: Water Well Inspection 13 Sample[3 Title Company <br />Sewage System Inspection 0 Address Tole. NO. <br />Escrow No. <br />Seiler Seller Address <br />Telephone No. Seller Agent Name <br />Service Request For Date <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />APPLicANrs SIGNATURE X Title Date <br />7% <br />FOR DEPARTMENT USE ONLY <br />n Amm-AX—�J2-7.94WIT 13 <br />"I"o tr/ ontowNo,OIssumme LMM r""90 Lm"Nef" <br />"ftWAw—RETuAKALL.00ft"Ta &18"0Ai"P*EpMTALo4u"LTI",T,/,S�ER"VICES tial EML-ron AVE, P.o. a.. 2m sTocKTow. cA am <br />ITTA14CE <br />DATE <br />"I"o tr/ ontowNo,OIssumme LMM r""90 Lm"Nef" <br />"ftWAw—RETuAKALL.00ft"Ta &18"0Ai"P*EpMTALo4u"LTI",T,/,S�ER"VICES tial EML-ron AVE, P.o. a.. 2m sTocKTow. cA am <br />