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Applications Will Be2 ssed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> 1 • ENVIRONMENTAL. HEALTH PERMIT/SERVICES <br /> ` ENGINEERS Al IF VEHICLE INVOLVED, GIVE <br /> APPyAGANT-S AND/OR FOOD ESTABLISHMENTS,HOUSING Make . <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING --- _- <br /> BROKER Al REAL ESTATE INSPECTIONS Lie. No. <br /> ICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> 1, t3ER Color <br /> 7/27/88 uUNOCAL Corporation <br /> Application Date Business/Name To Appear On Permit <br /> Review wc—- <br /> v,Type Permit/Servi R est d: <br /> z cUf0 RMest <br /> 2175 N. California, Suite 6509 Walnut Creep <br /> a ApplicantrName Ad�r s <br /> J r irr�rrt�a B siness Tele hone No. 4 I —7 76 Emergency Telephone No. <br /> 4107¢Property Location/Addres acs i.c Avenue, Stockton, California <br /> i li r4 (-M Corporation As aboIru <br /> a Property Owner _ _ Address <br /> L Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS TotaTBLu0cling 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 APPL3CANTS Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> C7 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 /> F '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 `,,fork plan–Evaluation of Soil and Ground–Water ContaTninati.nn, <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. 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 San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 / hlp <br /> APPLICANT'S SIGNATURE X f/ Title_ Project Geologist Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L Re ped by DateNv. Permit No. Issuarte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRNTAL HEALTH PERMIT/SERVICES 1604 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />