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Applications Will BeP ssed When Submitted Properly Completed. Be rTo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> ESTABLISHMENTS. <br /> APPLICANT'S AND/OR FOOD ES , MOUSING Make - <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIc. No. <br /> ,IrENSE AND/OR POULTRY RANCHES AND KENNELS Reg St. No.__ ---- <br /> STRATION MISCELLANEOUS SERVICES <br /> Color <br /> I. AER <br /> [Application Date Business/Name To Appear On Permit - - - - ---- <br /> VlType Permit/Service Requested: <br /> I­ <br /> Applicant Name 'Moore Petroleum Address P 0 Box 67 Banta 95304 <br /> Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 14800 lJ FrnntagP Rd=," Man era <br /> `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 <br /> ❑ 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 Tank Installation Inspection <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. 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 Da <br /> I hereby certify that I he p epared this application and that the work will be done in accnrda a with San Joaquin County <br /> ordinances, state laws, an rul 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 8 Received By January 31 July 1 6 Receiv d By July 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMO NT DUE C ECKED <br /> /p� DATE DATE REMITTED �Y A OUNT <br /> FEE 70 00 h S l 35 12 22 69 70 0 <br /> LESS er hr. - <br /> PRORATION <br /> PLUS pENA <br /> PENALTY "DUE ACCO JNM-3U-- <br /> OTHER DAY6 FR M BILLING ATE, <br /> OTHER <br /> � '7(j to <br /> Receivetl by _ of, <br /> te Receipt No Permit Na Issuance Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />