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Applications Will Be Proc'r d When Submitted Properly Completed. Be Sure T. Sign The Application. <br /> - ` APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIC <br /> EIF VEHICLE INVOLVED, GIVE <br /> R'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> RROkER AND/OR REAL ESTATE INSPECTIONS Lie. No. <br /> lrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION' MISCELLANEOUS SERVICES Regist. No. <br /> , , r3ER Color <br /> 3-24-89 <br /> fAppfication Date Business/Name To A NI <br /> II ppear On Permit <br /> ,o,Type Permit1,10,vice Requesfed: PriOritY ReVieW Of Site AsSeSSme 1 and Rik Remediation Plan <br /> P � <br /> u Applicant Name James Fran Address3 62 <br /> a Business Telephone No. 916 962-1612I Emergency Telephone No. Same <br /> *,Property Location/Address 7644 Ashley Road Stockton CA II <br /> Pacific Bell Telephone PaMIc Be ° IRProperty Ownerya Address <br /> [Operator's Name Mr. Steve K. Wat Address <br /> 1 FOOD ESTABLISHMENTS Total Building Sq. Footage estaurant, aximum Sea ing 'apacity <br /> ❑ RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESI11 i 13 MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR <br /> 11 ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATIONI ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No..of 7. ._ _.._ ❑ MO,BILE FOOD PREP„UNIT _ D,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 1 <br /> ❑ MOBILE HOME PARK/No. of Spaces II <br /> 3. WATER QUALITY 'E] WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULMR <br /> NO, OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOLVill <br /> NATUbAI RING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds IMAL <br /> r :ENNEL/Runways /Animal Population No. No. of Confi ing Cages 4 <br /> Sewage'Disposal Method I� if <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method I <br /> 6.•WCONSULTATION FEE II the Pacific l A Road <br /> 7. ❑ .PLAN CaECKING FE FI /Stockt dEadlily and the RemediationlIPlan1fors <br /> 8. REALESTA7E KXKXIXX Stockton Facility (UE-132) 7644 9991ky Ashley Road, Stockton, CA <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address I� Tele. No. <br /> Escrow No. <br /> Seller Seller Address I. I <br /> if <br /> Telephone No. Seller _Agent Name �- . <br /> Service Request For Date x <br /> �f II <br /> 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 /> RPC No.1 4534 <br /> APPLICANT'S SIGNATURE X /t Title Seinior Geoh drolo mate 3-24'$9 <br /> FOR DEPARTMENT USE ONLY 1pi� <br /> 1 &Received B Januar 3/ ❑ Jul 1 &Received B Jul 31 <br /> REMIT <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE El EACH ❑ January I y Y y Y Y <br /> BILLING REMITTANCE I$ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT_; <br /> FEE f it <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER I� <br /> r <br /> OTHER <br /> I I <br /> Received by, Date Receipt No. Permit No. ;I Issuance Date Mailed Delivered <br /> 44(( APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 9$201 <br />