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Applications Will Be Processed When Submitted Properly Completed. Be Sue Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING - - - -- - --- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIQ NO. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS R¢ ISL NO. <br /> 3TRATION MISCELLANEOUS SERVICES g - -- - -J. .BER -.---- <br /> Application Date _ Business/Name To Appear On Permit <br /> .Type Permit/Service Requested: _- - <br /> z Applicant Name --- Chevron/EA-Engineering—___ Address 41-A Lafayette Cir_, Lafayette-94549_-___ <br /> u- - -.- Business Telephone No. _._ _.__. ___.. Emergency Telephone No.— <br /> sProperty Location/Address -45- E_-Hdrding_Way>_Stkn <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 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 /> S. 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. Q CONSULTATION FEE UGST-Werk Plan Addpndtmt <br /> 7. ❑ PLAN CHECKING FEE _ <br /> 8. 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 X — Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a eived By January ❑ July/ 6 Received By July 31 <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED MOUNT DUE CHECKED <br /> ----- - - -- - -- AMOUNT <br /> FEE -_--. 63175 2L7L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY $ 6.38 Penalty 4/3/89 $70.13 <br /> OTHER--_ ___ __.- <br /> OTHER <br /> -- `�-E)CA 3 net LA - - <br /> --- - - — <br /> Recowed by <br /> Data Receipt No Penml No Issuance Date Mailed Delivered <br />