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Applications Will Be Proc d When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> ENGINEER'S AND/OR <br /> APPUCANT'S AND/OR FOOD ESTABLISHMENTS,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 ANO XENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No. <br /> BER �. <br /> Color <br /> Application Date- . 4-$9_ _. . Business/Name To <br /> � 3-2Appear On Permit . Ver53r I11C­ <br /> Type Permit/Service Requested: -P-niOritY-Re-i-EW Df Si-te.ASSes-sme_nt wl-d-. _ Ramedjz-tjz_n_T1 an <br /> `Applicant Name tadIll -frames, Vprsa r I nr_._ Address_5330 628 <br /> u <br /> 0. - - -- _.__ Business Telephone No. A-9-10-962-:1612. Emergency Telephone No. Sdine <br /> dPropertyLocation/Aaaress .7644 ASAI Road, Stockton-_CA_- <br /> `PropertyOwner PaCi_f1C Bt'11_ Tele hong - .. Addres-SPac7 lc -e �,- esign an ons ruc ion ro—pe rty <br /> LOperator's Name -Mr. StPve K. Nat ... Address 37101l7^---i nn�s May' <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage 'RQ taurant, a,imum Sea Ing apacity <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 /> S. QXCONSULTATION FEEthg-oriorit,y review of ; S�Assessmip for the Pacific Be1l Ashley Rna <br /> 7. 13 PLAN CHECKING FEn Facility and thp Rmicidiation Plan for-the- Pacifir RP11 Ashley Road <br /> e. REAL ESTATE RX9111% Stockton Facility (UE-132) 7644 SMAIRYC Ashley Road, Stockton, CA <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 /> 1 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, a d rules and regulations of the San Joaquin Local Health District. <br /> RPG No. 4534 <br /> APPLICANT'S SIGNATURE X Title Senior Geohydrologiztate 3-24-89 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS flue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 9 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <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 /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />