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i Appk*M M WIN ""n SuORlNbd Preyealy Calan Mo&N 0 T Bleu Ti AprA <br /> eaa <br /> SAN"JOA,UIN LOCAL HEALTH DISTRICT cE►vEtAl <br /> tYKiINEER3 Ale7/OR APPLICATION W VEHK"Bwourm. <br /> APPLICANTS ANOIOR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> R Lid.NO. <br /> LICENSE ANDPON MISS ERTAKONNU ,tsaea�e <br /> REGISTRATION PatiJeat��A7B aABKlSS Regi NO. <br /> NUMBER 394241 =4MATEaIpKIMM color <br /> PMM&AMC=AND ADIEU <br /> RINGELLAIRM� Jerry & Associates J <br /> (Application Oeste 6-20-86 Business/Name To Appear On Permit Y Jo Y <br /> .Type Perm t/Service Requested: fuel tank removal <br /> APpllcant Name Patten Rt-PPI Co, Tnr_ Address 1013 Shaw Rd. <br /> 8�jsi{�ess Telephone No. 465-5900 Emergency Telephone No. 465-5900 <br /> Property Location/Address 10 aw "" <br /> Property Owner Patten Steel Co. , Inc. Address 1013 aw Kd. <br /> LOperator's Name Boyd Patten Address Shaw <br /> 1. FOOD ESTABLISHMENTS Total Building Sq, Footage Restaurant,Maximum Soa*V Capecity _ <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET - � <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT - <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators -? <br /> i HOUSING <br /> ❑ HOTEtJMOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> S. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/RUnways /Animal Population No. ND.of Confining Capes <br /> Sewage Disposal Method �tr <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> e. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PUN CHECKING FEE ❑ DANCE PERMIT <br /> t REAL ESTATE <br /> REQUEST: Water Well Inepeepon❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tells.No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certlty that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state Is",and rules and regulations,of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title Qyrvsti!I,I Date <br /> OR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JMMwY I a RacaNed ay J n,31 ❑July 1 a Ra ed sy <br /> BILLING REMITTANCE a REW <br /> BASE EXPLANATION DATE DATE REMITTED AMOIMT DUE CHECICED <br /> AMOIMi <br /> FEE <br /> LESS <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recants W DaN Rawipl Nopl and NO. 1rw Oaw Mable OaMvMW <br /> APfLICANr—A[TUANYLfbYatD: LllYIaOMY[1rTLL NEALIT/P[AYrTAt11YICle teat C HA=LTOFI AVE.P.O.ew M IFTOCRTOK CA seals <br />