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v Applications WIII Be�essed When Submitted Properly Completed. B#To Sign The Application. <br /> APPLICATION <br /> ! ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ARD/OR V FOOD ESTABLISHMENTS,HOUSING Ma --- - <br /> APPLICANT'S AND/OR PUBLIC POOLS, SPECT SAMPLING <br /> CONTRACTOR AND/OR REAL C TAYEPOOL INSPECTIONS <br /> SA 1 -- <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS _ <br /> jr.ENSE AND/ORg15 <br /> STRATTON MISCELLANEOUS SERVICES - _- <br /> I, .BER <br /> f Application Date Business/Name To Appear On Permit <br /> MI Type Permit/Service Requested: _D3. Pox 57, Banta 95304 <br /> 5 Applicant Name IAOOre Petroleum Address - <br /> Y Business Telephone No. Emergency Telephone No. <br /> i Property Location/Address 14000 W. Fro <br /> ntag^ Ld. , Manteca _ - ----- <br /> Property Owner Address - <br /> LOperator'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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <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 /> Animal Waste Disposal Method <br /> Water Supply Source — -- <br /> 6. ❑ CONSULTATION FEE Tank Tnctallatinn Tnsrartinn (FRANK14) <br /> T. ❑ .PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection C1 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 DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January Ol ❑ July 1 A Received By July 91 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE r L hr, 0 3 f g /0,00 <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY F_A_py�l. <br /> OTHER <br /> AYS <br /> LI <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo,2009 STOCKTON.CA 95201-- — <br />