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Applications Will Be Prr 'sed When Submitted Properly Completed. Be Su -o Sign The Application, <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES UNIT III <br /> 'ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> • WENSE AND/08POULTg7 RANCHES AND KENNELS <br /> Lic. No. <br /> STRATTON <br /> I. AER MISCELLANEOUS SERVICES Reg st. No. <br /> Color <br /> Application Date 9-27-90 Business/Name To A <br /> -- ppear On Permit ________________ <br /> MType Permit/Service Rg�qque led:- <br /> 1- <br /> 24 <br /> ed: <br /> u Applicant Name LWBe?RT & SONS _ Address -- <br /> OTIERFORD, CA -9-58-F6- Businj TgI¢phopg No. __ Emergency Telephone No. <br /> 'g Property Location/Address__ 611 N. Mei IN — UtLfH BHIVK <br /> Property Owner DELTA_BANKAddress_ 6 <br /> LOperator's Name —VON—DAL BEN _ 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 — UNDERGROUND TANK REMOVAL <br /> ALL APPLICANTS: Total Employees Including Operators INSPECTION <br /> 2. HOUSING <br /> ❑ HOTEUMOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER DUALITY ❑ 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 /> 6. 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 /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July/ S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OVE CHECKED <br /> AMOUNT_ <br /> FEE $35.00 TANK REMOVAL INSPECTI N 10-5-90 35.00 <br /> LESS <br /> PRORATION <br /> PLUS $3.50 PENA 11-5-90 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Pemut No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa No STOCNTON.CA 95201 <br />