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yrs Applications Will Be Processed When Submitted Properly Completed. De Sure in The Applicehon. <br />,r"•.. �, APPLICATION! <br />E RONMENTAL HEALTH PERMIT/SER/� <br />T"tI <br />INVOLVED, GIVE <br />FOOD ESSAtILtSkMERTS. NEIUSING /�� Me - <br />r r�TFr PUBLIC POOLS. NATER SAMPLIND ^I L <br />H^i hEF Ar :, FILM ESTASL tNSpEGTi61t5 �l�/�r, f �� Lic N <br />AWj - POULTRY RANCHES AND KINNtI-S ! <br />;TctAT10' IMIISCLLLANEDUS SERVICES Jlt� �p, t N <br />niu�/T � �Cc/o,or <br />5-26`88 MONTGOMERY WA HSI, <br />v ' ,, Business'Narne To Appear On Pe.rrrit -- �-r-- �- <br />- t <br />-vice Re::.:ested Underground Storage Tank Closure _ <br />~ <br />Applicant NHnie North Cal Construction P 0. Box 588> Stockton CA 95201 <br />c Address <br />e Business Telephone No. _(209) 465-5886 ��_-- _ Emergency Telephone No <br />Property Loc:altonlAddress 5400 Pacific Avenue Stockton- CA 9 92f <br />1Property Owner _Montgomery Wards Address --5400 Pacific Avenue, Stockton, Ca 95207 <br />4 <br />C ;, erate,r's Mame 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 ❑ LIOUOR 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 />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 <br />7- PLAN CHECKING FEE $390.00 <br />8, REAL ESTATE <br />REQUEST: Water Well Inspection 13 Sample❑ Title Company <br />Sewage System Inspection ❑ <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />Seiler Address <br />Seller Agent Name - <br />Tele. No. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with Sane Joaquin County <br />ordinances, state lawn 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 Is Due: D ANNI )ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Recprved @y January 31 ❑ July 1 A Received By July 31 <br />FEE <br />LEY, <br />PROPAT ION <br />PLUS <br />PL NAL t Y <br />IDTHEq <br />01 Ht I+ _ <br />APPS IC A —Iif 1lrRN Ali COMII E 10 <br />FFBILLING <br />BASE <br />EXPLANATION DATE <br />REMITTANCE <br />DATE <br />f <br />REMITTED <br />AMOUNT DUE <br />REWT <br />CHECKED <br />AMOUNT <br />----------------- <br />t— <br />- --.._._fro; r / �Pp-nii! No <br />FNJIRONMENTAL MLAITH P#KNIT rOF RYICE3 <br />---ra4uance Dete Maded De -f -roll <br />4601 E HAZELTON AYE PZ, gam IM $1'OCMTON CA 0440`.-- -^ <br />