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Applications Will Be Passed When Submitted Properly Completed. Be 0T Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR E000 ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> Ir'E 3TR AND/OR POULTRY RANCHES AND KENNELS <br /> I, BER Lic. No. _ <br /> ATION MISCELLANEOUS SERVICES Regist. No. <br /> . _ <br /> Color <br /> (APPlication Date Business/Name To Appear On Permit <br /> oType Permit/Service Requested: - - <br /> Applicant Name Moore Petrol urn <br /> Address_ P. 0. Box 67 Banta 95304 <br /> Z Business Telephone No. Emergency Telephone No.. <br /> `a Property Location/Address 14800 W Frontage Rd M nter <br /> J Property 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 /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F :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 /> 8, ❑ CONSULTATION FEE Tank Installation Inspection <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 IN Seller Agent Name <br /> Service Request For Da <br /> I hereby certify that I ha p epar6d this application and that the work will be done in acrarda a with San Joaquin County <br /> ordinances, state laws, an rui s d r ulati ns 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 1 A Receiv d By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ EMIT <br /> DATE DATE REMITTED AMO NT DUE C ECKED <br /> A OUNT <br /> PEE 70 00 h s 0 35 12 22 89 70 0 <br /> LESS <br /> PRORATION er hr. <br /> PLUS <br /> PENALTY PEN - <br /> OTHER 9AY5 FR M BILLWG ATE, <br /> OTHER <br /> o co S— 7cj <br /> L_.___2.ce,veo by D t Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />