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A <br />s` <br />Applications Will BePlassed When Submitted Properly Completed. Be Sure IT, Sign The Application. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT GENERAL <br />ENGINEER'S AND/OR <br />APPLICATION <br />APPLICANT'S AND/OR <br />❑ FOOD MARKET WHOLESALE <br />CONTRACTOR AND/OR <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />BROKER AND/OR <br />❑ ICE PLANT <br />LICENSE AND/OR <br />FOOD ESTABLISHMENTS, HOUSING <br />REGISTRATION <br />PUBLIC POOLS, WATER SAMPLING <br />NUMBER _ <br />REAL ESTATE INSPECTIONS <br />❑ FOOD SALVAGER <br />POULTRY RANCHES AND KENNELS <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. — <br />Regist. No <br />Color- <br />MISCELLANEOUSSERYICES Shell 011 CO. <br />[Application Date Business/Name To Appear On Permit <br />*Type Permit/Service Requested: <br />�Applicant Name Shell 011 Co. Address P. 0.—Box 13678, Sacramento 95 553 <br />U <br />a. - _ Business Telephone No. _ Emergency Telephone No. —_ <br />Property Location/Address 3725 Tracy Blvd. , Tracer <br />Property Owner __ Address _ <br />L Operator's Name Address <br />1. FOOD ESTABLISHMENTS <br />Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL <br />❑ FOOD MARKET WHOLESALE <br />❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT <br />❑ COMMISSARY <br />❑ ICE PLANT <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ LIQUOR STORE <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE <br />❑ FOOD SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of <br />$70.00 <br />❑ MOBILE FOOD PREP. UNIT <br />❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />2. HOUSING <br />❑ HOTEL/MOTEL/No. of Units <br />❑ MOBILE HOME PARK/No. of Spaces <br />❑ CERTIFICATE OF OCCUPANCY <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 <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />6. CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />B. REAL ESTATE <br />/Animal Population No. <br />REQUEST: Water Well Inspection 13 Sample❑ <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />❑ NATURAL BATHING PLACE <br />No. of Confining Cages <br />Animal Waste Disposal Method <br />0 BUSINESS LICENSE <br />DANCE PERMIT <br />Title Company <br />Address _ Tele. No. <br />Seller Address <br />Seller Agent Name <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 r s a d re ulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATU _ Title < //�'s.�C.`_ Date f_yh e if <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 />BASE <br />EXPLANATION <br />BILLING REMITTANCE' $ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE DATE REMITTED <br />AMOUNT <br />FEE <br />$70.00 <br />Reinsnecti <br />n 12/6/85 Due.IMMEDI TELY <br />$70.00 <br />X <br />LESS <br />d_ <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />19 <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />�oe� �e��r—een aau u � rne�ee tn• cuvmnuucur., <br />. HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 25201 <br />