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�� �,jMMM�wa►rYu• E�uur rr�+'- rr�Y rYlrru JJNN1/\\iJ . .aE.wr.Z \.uurVaie u. u� J � J.yu 7ue nNMuti4 �,, <br /> �i.1rM!'1:-..VLM^�',%� "'R � �rt.".. '< .N:�+;°�11��•�\. 4`t,���,� 11 I I <br /> 'I- ENVIRONHPERMIT%8LiiVICE8 .5, , t <br /> ENGINEER'S AND/OR IF VEHICLE OWED,•GIVE <br /> APPLICANT'S AND/OR F000 ESTASUSNMENTS.MOUSING Make Y' `' " <br /> CONTRACTOR AND/OR PUGLIC POOLS,(MATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. - <br /> IrENSE AND/OR POULTRY RANCHES ANO KENNELS I� <br /> GYRATION MISCELLANEOUS SERVICES <br /> CO 1 r Regist.No. <br /> I. .aER __._-_._. __ Color . <br /> (Application Date __1-14-U$ Business/Name To Appear On Permit <br /> PHOTOCOPY OF RECORDS - BEECHNUT AND 11TH ST. , TRACY p <br /> Type Permit/Service Requested:- � <br /> Applicant Name _______________ �5 E. 10TH, TRACY, Tay BLVD. & BEECHNUT RD. , TRACY <br /> RADIAN CORPORATION_ Business Telephone No. Emergency Telephone No. <br /> Property Location/AddressATTEN;___ _SUSAN S .H I. RF.I.1~ 10395 OLD E RD SACRAMENTO <br /> 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 /> ❑ HOTEUMOTEL/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 - <br /> 7. ❑ PLAN CHECKING FEE -- -- - -- - ---------------- -- — - - <br /> 8. REAL ESTATE <br /> REQUESTWater Well Inspection C3 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 /> APPLICANTS SIGNATURE X Title __ Date - ----- <br /> FOR <br /> ate______FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUAL Y ❑ f-I n uNlr ❑ PIH ,Ilt ❑ EA<,tl ❑ January 1 6 Received fay January 31 ❑ July 1 6 Received By Jul, 31 <br /> l j - - _. - REMIT <br /> HILL ING REMITTANCE S <br /> I RASE f xPt ANA f LUN AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> PEE $30 . 00 L10 . REVIEW AND COPY RE U�STED INFO <br /> LLss i - — <br /> PRUHATION i <br /> PLUS <br /> PENALTY <br /> OTHER 9 .60 ; ES Q.10 - <br /> 01HEH 2 . 40 j POSTAGE $42 . 00 <br /> Rece ved by Dale Rece.pt No Permit No Issuance Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2002 STOCKTON.CA 9520 <br />