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• ��� ' Applications Will ftessed When Submitted Properly Completed. Befto Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> BROKER AND/OR Lid. NO. -- <br /> LICENSE AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> REGISTRATION PUBLIC POOLS WATER SAMPLING Regi31.NO. _ <br /> NUMBER 496073 REAL ESTATE INSPECTi0H3 Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date-9-2-86 Business/Name To Appear On Permit KAYO OIL CO. <br /> .Type Permit/Service Re ted, KLMUVE & INSTALL UNDERGROUND STORAGE TANKS _ <br /> Applicant Name fy.6 Oi (, LM. cu PSMIAddress 1023 GEORGE AVE. <br /> N. LAS VEGAS, NV 89030 Business Tpjepho a No. — — Emergency Telephone No. 702-381-3748 <br /> Property Location/Address 15'-3 F. // s41 L <br /> iProperty Owner KAYO OIL CO. Address 1221 E. MAIN ST. F CHATTANOOGA, TN 37408 <br /> LOperator'sName KAYO OIL CO. Address 1221 E. MAIN ST CHATTANOOGA TN 37408 <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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEUMOTEL/No.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 /> Water Supply Source Animal Waste Disposal Method <br /> S. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. b PLAN CHECKING FEE & TANK PERMIT FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE 30 + 270 = 300 <br /> REQUEST: Water Well Inspection 13 Semple[] 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 certifyI hay this ap n and that the work will be done in accordance with San Joaquin County <br /> ordinances,SrrE � <br /> red rules and egu Ion the San Joaquin Local Health District. A Q�rA <br /> APPLICANT'S SIGNATU Title �e Date a r�u v <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ;L-7p AMOUNT <br /> FEE0 .Q0 3 +ctn\ rCW10V 4Q• 0 CaGS, <br /> LESS <br /> PRORATION 3o_•OE1 I(b k eGle -GI-3n -}— '300-00 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> RA <br /> Recened by Dale Receipt No, Permit No. inate Mailed Delivered i <br /> APPLICANT—RETDBR PnataaTM ONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA N AVE.,P.O.Bee 2M STOCILTOK G1 l w <br /> A <br />