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Applications Will Be Prosy ssed When Submitted Properly Completed. Be Sure 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 FOOD ESTABLISHMENTS. HOUSING Make nL.a_ <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. ._..- <br /> 1rENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO.— <br /> STRATION MISCELLANEOUS SERVICES g -- <br /> I. ZER Colo! <br /> Application Date-If 14 4 Business/Name To Appear On Permit CHEROKEE_ SERVICE CENTER _ <br /> viType Permit/Service Requested: Soil contamination re—excavation — review <br /> i Applicant Name LLOYD P. GUMS Address. 303 S. Cherokee, Lodi, CA 95240 <br /> 4 BusinessTelephoneNo. 209-333-1939 Emergency Telephone No916-446-6416 <br /> i Property Location/Address 303 S. Cherokee Lane, Lodi, CA_95240 <br /> JProperty Owner Lloyd P. GUMSAddress 731 Birchwood, Lodi, CA <br /> I Operator's Name _-- Same — Address — Same — <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Sealing 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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :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. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST. Water Well Inspection[] 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 a e prepare thi a plication and that the work will be done in accordance with San Jo uin untyl <br /> ordinances, state laws d r :as a d eg I io f the San Joaquin Local Health District. 1Yo1 <br /> APPLICANT'S SIGNATURE X Title OWIIEY Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE Review al field imspectio 70 .00 70 .00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERq G i <br /> �/ 1����0 <br /> Rec by Date Rai No. Permit No Issuance Date Mailed Delivered. <br /> A PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.NAZELTON AVE.,P.O.Boz 2111011 STOCKTON,CA 95]01 <br />