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Applications Will Be Processed When Submitted Properly Completed.Be Sure)o Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make <br /> BROKER AND/OR LIC. No. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING Regist. No.. <br /> NUMBER REAL ESTATE INSPECTIONS Color _ <br /> POULTRY RANCHES AND KENNELS <br /> AUG. 30 1984 MISCELLANEOUS SERVICES lit <br /> *Application Date r BUsiC To Appear n Pe I TEXACOLS 1 N__C_._ \ <br /> *Type Permit/Service Requested:�,�r ,._ _r\�etD . J�LI-_- <br /> z Applicant Name TEXACO, USA, INC.- Addres-- -CUTTING BT VD- r RTC]Q0 CU N1TCA_ 94804 <br /> Business Telephone No. 415/232-7671 _ Emergency Telephone No. <br /> $Property Location/Address 440 WEST CHARTER WAY, STOCKTONLCA 95206 <br /> — - – - <br /> Property Owner TEXACO, USA _ _ Address SAME AS ABOVE <br /> L Operator's Name TEXACO, USA Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, 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 GASOLINE SELF—SERVE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING N/A <br /> ❑ HOTEL/MOTEUNo. 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 <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. 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 Disposal Method <br /> Wer Supply Source Animal Waste Disposal Method <br /> 8. CONSULTATION FEE " a ❑ BUSINESS LICENSE <br /> 7. PLAN CHECKING FEEL ,fi,,jq ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ Tele. No. <br /> Escrow No. <br /> Seller _ Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and r and re lations of t an Joaquin Local Health District. <br /> AGENT FOR <br /> APPLICANT'S SIGNATURE X Title TEXACO, USA, INC. Date AUG. 30, 1984 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE C S. <br /> LESS as PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER —^ <br /> a <br /> m <br /> OTHER <br /> n <br /> 0-k-- °=VI-t/L <br /> 0 <br /> 0 <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RETLRNILL CORMS.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 w <br />