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Applleatleha Ww Irl.Mrt d rMreri Subnintid Prope+t completed I saw. fitrn file AppMeaNMir. <br /> t - SAN`JOAQUIN LOCAL HEALTH DISTRICT t;QrI JAL <br /> ENGINEFFM" APPLICATION VEllow wwaVw• <br /> APPLICANT'!ANOMR 't Maks <br /> oatR AND/OR ENVIRONMENTAL HEALTH PEPwrisERVICES <br /> Lid.No. <br /> "E"M Am"* 394241 f AfINNMtET>R MN+MM' Reglet.No. <br /> RttpISTRATION FVKJ' WAM SArMRtMM. <br /> NUMBER _ I1FA4 At[Mlaf'ttoTm" GoftX <br /> PS KM AAIACMf>t ASM UIbME A <br /> 10-27-86 Jerry Joy & Associates <br /> rApplicetlon Date ausintis�lName To Appear 01 Pgrr�it <br /> Type Permit/Service Requested: un erground tank remova /c o <br /> 10U0 N <br /> Applicant Name Jerry .Toy & Associates Address neon St. - 1 <br /> Business Telephone No._466-1561 Emergency Telephone No. <br /> Property Locetlgp/Addresp—$88 E. Lindsay-Street <br /> Property OwnAr 146nry Wolt8XS &, Son _ Address 888 East Lindsay St. <br /> LOperator's Namts _Samp 1' Address <br /> t. FOOD EOASLISHMENT$ total Building Sq. Footage Restaurant.Maxlrhum Soathq Capacity :. <br /> 13 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 Op store <br /> 2. HOUSING <br /> ❑ HOTELIMOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> ]. WATER QUALMY ❑ WATER SAMPLE(Bacteririll ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Cohhee") <br /> s. RECIIEATIONAL HEALTH ❑ SWIMMING PQOL 13 'SPA ❑ WADING POOL 13 NATURAL BATHING PLACE <br /> S. VECTOR COWAOL ❑ POULTRY FARMiMskxlrhurh No.of Birds ' <br /> ❑ KENNEL/Runwayi /Animal Population No. No:of Confining Qbo" <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method =+ ' <br /> Water Supply Source Animal Waste Disposal Method <br /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water WNI inspection❑ Sainpie❑,I Title Compdny <br /> Sewage System Inspection ❑ Address Tek.No. <br /> Escrow No. <br />' Sellar 1. Sellar Address <br /> • Telephone Nd. Seller Agent Name <br /> ServiCe Request For Dote <br /> I hereby ae►tlly that I hive p rid this a cation trnd that the work wile_be In accordance with San Joaquinordinances.$11818 lawt,and ru end reguist ns bf the San Joaquin Local trtd. <br /> APPLICANT'S SIGNATUR Title Dale <br /> R DEPARTMENT USE ONty <br /> Fee 1$Due:❑ ANNUALLY ❑ PERU T 13 PER SITE 13 EACH 13Jalmari I a Recehod,M January 11 E3 J,*ISR"a <br /> ROMT <br /> flASE EXLNA4ok ®ILL.INd REMITTANCE'. $ AMOL1NTVlE CHEMN <br /> DATE DATE RIM TtEt3 AMOLINT <br /> FEELESS <br /> 1 <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Recehrod by DIM Receipt NO. Permit No. Issuance Data Malted tbllrand <br /> APPLICANT—RETURMALL0001IR& D: 1104*00MIENTAL HEALTH}[RMIT/ithVic" /iM L HA2KTOM A".R0.Moa=0 611=:'OK CAlllldl#.,.. <br /> Ii r <br />