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• yCo`rr (Z ` c� - <br /> • APPSo doro WSI M Prorwaad WMn Sllt M%d Propane CaePM" w Sue TO Sign The Apgeeaeera <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ENGINEERS AND/OR rANERAL <br /> AND/Oq APPLICATION 1F VElpCLE NroLr�, <br /> oNTaACT aoR ENVIRONMENTAL HEALTH PERMIT/SERVICES Maks _ <br /> ICE D/OR FM Lid. No. <br /> NUMBERATIONl� )lJ / �.�EttEsam <br /> M Rag{aL NO. <br /> ([ !!! / ■Y Fl7aTE INrEL7MN Door <br /> Ia1RTaT atlGlNa AN*aEapELs <br /> Application Date 10-1-86 Iascaimm serill <br /> Business/Name To Appear On Permit Jerr Jo and Associates <br /> .Type Permit/Service Requested: Tank Bemcival <br /> Applicant Name .Terry jnO7 and Associates Address 1000 N. Union Street :. <br /> _ c+nok-I-nn . r'- g9205 __ Business Telephone No, 462-1481 Emere 462-148 <br /> Property Location/Address 9 ncy Telephone NO. 1.: <br /> Property Owner IV stmentAddress <br /> "31 F W r Ave, Stockton <br /> tOperator's Na me_dE?e Risl4wa-7A Address —_ 231 R WPher AyP . Si-k . 992g �5 <br /> 1. FOOD ESTASLISHMENTS Total Building Sq, Footage Restaurent, Maximum Seating capacity <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 /> 2. HOUSING <br /> ❑ HOTEVMOTEVNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces -�^ <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER -i <br /> NO. OF PUBLIC SERVED(ConnwiOns) <br /> e. 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. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disoos ll Method <br /> Water Supply Source Animal Waste Disposal Method <br /> a. ❑ CONSULTATION FEE C3 BUSINESS LICENSE <br /> 7. 11 PLAN CHECKING FEE 13DANCE PERMIT <br /> S. REAL ESTATE <br /> :3 <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tole. No. < -" <br /> Escrow No. <br /> Seller Seiler Address <br /> Telephone No. Seller Agent Name - <br /> Service Request For Date <br /> I hereby cartHy that 1 have <br /> prepared this spot tion and that the work will he done In accordance with San Joaquin Ctwrlty <br /> ordinances,state laws,and Iva and ragulatl S of the San Joaquin Local Health District. <br /> APPLI SIGNAT Title President Data 10-3-86 <br /> OR DEPARTMENT USE ONLY <br /> FN la Due: ❑ ANNUALLY ❑ R UNIT El PER SI E ❑ EACH ❑ January 1 a Racei•wi By Jamnry 31 ❑Ally 1 a Rawwi By AMY" - • <br /> BASE EXF ANATICN BILLING REMITTANCE- S REWT <br /> DATE DATE REMITTED AMOUNT DUE CHECKEWO <br /> FEE ,v' � AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS .•.:: <br /> PENALTY <br /> OTHER <br /> a <br /> OTHER <br /> X133 <br /> Raranep W Oat. R Pt No Parmir No. laaurue Data Mailed n.awr.s <br /> AEPLKANT—AlTUeNALLGOarta TO: ENY00MM[rRAL HEALTH KRMRnlernV s tam L IIAmTOR AM PA.aq/wa}OCR}pa CA Son <br />