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Applications Will Be P, '-sed When Submitted Properly Completed. Be c 'o Sign The Application. <br /> .�„ APPLICATION 1 <br /> _ UGCT PROGRAM ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING PAYMENT Make - <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS RECEIVED N`. <br /> ED L'IC. No. <br /> IrPNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No.—. — --- <br /> 3TRATION MISCELLANEOUS SERVICES OCT 15 1990 Color <br /> I. .BER ---___. <br /> SAN JOA.Qi.'!N (: . r•!iV <br /> I <br /> Application Date— 9-10-90 Business/Name To Appear On Permit __P_UBLL<_FFAI 7'' .;� <br /> ra Type Permit/Service Requested: <br /> FILE REVIEW/RECORD—RELEAAIRONME"JTALwu,Ll/1 �!`+'!�! <br /> i Applicant Name RMT INC, .—BRAD J MELVIN Address 3250 OCEAN PARK BLVD STE 370 <br /> ° SANTF MONICA. CA 90405 Business Telephone No. Emergency Telephone No. <br /> e 19101 F RRANnT 72405 E RRANDT RD <br /> 'Property Location/Address s <br /> iProperty Owner Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLEgALE ❑ 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 /> 6. 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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. � / <br /> APPLICANT'S SIGNATURE XA�A T!tle \ rDate AY,9_1i90i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ pMOU T DUE CHECKED <br /> —LDO DATE REMITTED AMOUNT <br /> FEE $20.00 FILE REV' EW/RECORII RELEASE 0 <br /> LESS VG AC UIRS <br /> PRORATION um OWNG <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 20.00 <br /> Received by Date Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 3008 STOCKTON.CA 95201 <br />