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+ Applications Will Be P, �sed When Submitted Properly Completed. Be S' ,To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR PND/OR PUBLIC POOLS,WATER SAMPLING <br /> B_POKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> 'NSE AND/OR POULTRY RANCHES AND KENNELS Reglst. No. <br /> TRATION MISCELLANEOUS SERVICES <br /> tli,�.EIER Color <br /> Application Date October 14, 1988 Business/Name To Appear On Permit Nomellini Construction <br /> oType Permit/Service Requested: Review Soil Excavation Work Plan <br /> i Applicant Name Nomellini Constriuction Address 939 West Charter Way. C ock on CA 95906 <br /> Business Telephone No. Emergency Telephone No. <br /> %lPAnperty Location/Address 1045 West Charter Way, Stockton CA 95206 <br /> Property Owner Nomellini Construction Address <br /> -�Oparator's Name 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 <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/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 /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> '.ENNEL/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 /> 6. 12 CONSULTATION FEE Review coil Excavation work Plan PAY11" 1T <br /> 7. ❑ PLAN CHECKING FEE $35.00 Proposal Review sjy(�(ED <br /> B. REAL ESTATE <br /> REQUEST: Water Well InpAk14n13 Sample[] Title Company <br /> Sewage Syst - Ih action ❑ Address Tele. No. <br /> Escrow No. ..f RpNN1ENTAL' WITH <br /> Seller Seller Address KES <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <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, an utas andregul t s of the San Joaquin Local Health District. ,�,/�� „ <br /> APPLICANT'S SIGNATURE X Title P��sf N � Date d• 9 86 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ JU140 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 8`Z�.l� <br /> Received by Date i,�ceipt No. Permit No, I' a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NRELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />