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Applications Will Be Proc ssed When Submitted Properly Completed. Be Sure—o Sign The Application. <br /> APPLICATION <br /> ENGINEERS AND;OR <br /> E VIRONMENTAL HEALTH PERMIT/SERV %, S <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make . _- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> rFNSEAND/OR - -------. -- _— <br /> POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> Color -- --- —_ <br /> -Application Date 10-24-88--_----__ Business/Name To Appear On Permit M- & R PACKING--COMPANY <br /> Remediation for Underground — <br /> ,n Type Permit/Service Requested: Soil Re <br /> g ound Tank closure <br /> z Applicant Name Donald- R—Reynalds,— __ _ - —_ __ Address 33 RT__Toka-y S1_r— <br /> a - - Business Telephone No. -2-009-169-2725- .__- Emergency Telephone No. <br /> c Property Location/Address 405-South Main c+r + -Lodi,-Ca 95240 <br /> aProperty Owner -M-&-R Company _. _- -. Address -33-E_-Tolrc,.9-3-_ctx ooh_xxU ral q 40 <br /> Operator's Name _ SAMR-pS-ABroX7E— 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. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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 Titlel>>e� t% _ Date QG, <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> — r AMOUNT <br /> FEE 3✓1 a LESS <br /> PRORATION 3 Q �) <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ived by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />