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Applications Will Be Prod When Submitted Properly Completed. Be So 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 <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> C COKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir-ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> .8ER _____—____..___ Color <br /> AMC Job No. 82470 <br /> f Application Date 11 16/9 0 Business/Name To Appear On Permit <br /> oType Permit/Service Requested: Soil SamT 1 i nQ on recon l- da-y--_ <br /> QApplicant Name_- —tcari En�li ronmental _— Address-9.719 Lincoln 1j---age Drive <br /> Ste. 501 , SaC_r-allen o_, CA E9j5I s7Telephone No Emergency Telephone No. <br /> a Property Location/Address— 27 81 MacArthur , Traci; CA 95376 <br /> dProperty Owner tead Land Level nn_Tment__ Address <br /> a <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 /> 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. OXCONSULTATION FEE ' Sampling a ftpr raMpVal of tank— �-18� 088 gal K esel <br /> 7. ❑ PLAN CHECKING FEE on 11-16-90 <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample 13 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $35 . 00 S <br /> LESS ti <br /> PRORATION <br /> PPLUS <br /> ENALTY $8 . 75 Penalty 1/9/91 $96 , 2 <br /> OTHER A ' <br /> C <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> inni F ax 2009 CKTON CA 95201 <br />