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-- Applications WIII Be Peed When Submitted Properly Completed.Be*To Sign The Application. <br /> APPLICATION <br /> ENGINEERS AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS.NOOSING IF VEHICLE INVOLVED, GIVE BROKER AND/OR PUBLIC POOLS.WATER SAMPLING Make Ir.E REAL ESTATE INSPECTIONS <br /> . AND/OR POULTRY RANCHES AND KENNELS Lic. No. <br /> 3TRATTON <br /> STRMISCELLANEOUS SERVICE <br /> I. .dER $ Regist. No. <br /> Color <br /> [Application Date __. _ Business/Name To Appear On Permit <br /> wType Permit/Service Requested: <br /> Applicant Name Moore Petrol a ,m Address P 0 Box 67 Banta 95304 <br /> a Business Telephone No. <br /> i Property Location/Address 14800 W. Frontage Rd Emergency Telephone No. <br /> Man P a <br /> `Property Owner _ _. <br /> "[Operator's Name Address <br /> 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 ❑ <br /> ❑ ROADSIDE FOOD STAND 13 LIQUOR STORE 13 BAR BAKERY <br /> ITINERANT RES <br /> ❑ CONFECTIONARY STORE 13FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR TAURANT <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 Tank Installation Inspection <br /> 7. ❑ .PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection El 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 1 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 <br /> Da <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Recei d By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED DUN ED <br /> FEE 70 00 h s 0 35 12 22 89 AMOUNT_ <br /> Q <br /> LESS $7 0 <br /> PRORATION er hr. <br /> PLUS <br /> PENALTY PEN <br /> OTHER BAYS FR M BILLING ATE, <br /> OTHER <br /> Received by Ogle Receipt No. Permit No. <br /> Issuance Mailed Dd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NA2ELTON AVE..AP.O.Boa 209 $TOCKTOCXTON.CA 95101 <br />