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Applications Will Be Pror ad When Submitted Properly Completed. Be Surf To Sign The Application. <br /> A. `.' APPLICATION I -, <br /> AINEER'S AND/OR <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ' <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENT&HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .,3ER RECAL14 <br /> QOIOr <br /> f Application Date 10/16/u91 Business/Name To Appear On Permit <br /> a Type Permit/Service Requested: <br /> (Applicant Name Re'lal Station #604 Address 1448 N Ei toc ton, a - <br /> O — <br /> I Business Telephone No. Emergency Telephone No. <br /> `Property Location/Address 1448 N El Dorado <br /> i Property Owner Wickland Oil Co � Address 1765 Challenne - :cramento, Ca nn�1 <br /> -[Operator'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 /> 13 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 :ENNEURunways /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 /> B. ❑ CONSULTATION FEE �..atmt,- location- <br /> 11 <br /> T. C] PLAN CHECKING FEE r. S T RFnAI 1d�S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 have prepared this application and that the work will be done in accordance with n Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 K Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $35.00 per hour x 3 1/2 hours for 98/29/ 9 8122,50 <br /> LESS <br /> PRORATION $35 00 pe cnci, tinn nn inf,31pq <br /> n <br /> PLUS <br /> PENALTY <br /> OTHER Q <br /> OTHER <br /> Received by Date \...,ecelpt No, Permit No. 1 a Date Mailed Delivered <br /> APPA2 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HELTON AVE.,P.O.bx 2009 STOCIRON.CA 95201 <br />