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Applications Will Be Procer When Submitted Properly Completed. Be Sure -• Sign The Application. <br /> APPLICATION `I <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ANO/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> APPLICANT'S ANO/OR PUBLIC POOLS WATER SAMPLING <br /> CONTRACTOR ANO/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> BROKER ANO/OR POULTRY RANCHES AND KENNELS <br /> r I!NSE AND/OA Regist. No. <br /> I <br /> STRATION MISCELLANEOUS SERVICES Color <br /> `I. .d ER <br /> Application Date <br /> 3/28/89 Business/Name To Appear On Permit Gold Bond Building Products <br /> .Type Permit/Service Requested: ton on, CA 95203 <br /> <Applicant Name Gold Bond Building Products Address X00 West Church Stock_ <br /> Business Telephone No. 1,209) 466-5251 Emergency Telephone No.(209) 466-5251 <br /> ,Property Location/Address 800 West Church, Stockton, CA <br /> JProperty Owner <br /> Gold Bond Building Products Address 800 West Church St. , Stockton, CA 95203 <br /> LOperator's Name Michael J Rogge Address 800 West Church St Stockton CA 95203 <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 /> „0 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 :ENNEVRunways /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 /> S. S CONSULTATION FEE Closure Plan for underground tankg, Gump and piping <br /> 7. C1PUN 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 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, jAd rules and regulations of the San Joaquin Local Health District. <br /> �fj/_ C17L Regional Mgr.-Engineering <br /> APPLICANT'S SIGNATURE <br /> "'—_ erican Env ronmenpa� 3/28/89 <br /> emen <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receive By January 31 ❑ July 1 A Recev d By July 31 <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCE f AMOUNT OUE CHEOKEO <br /> GATE GATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �Recerve0 by Dale Receipt NO PermH NO Ivvance Dib MnJae DellVareC <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONYENTAI HEALTH PERMIT/SERVICES ta01 E.HA2ELTOH AVE..P.O.aea A09 STOCKTON,OA 9S3p1 <br />