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Applications Will Be Pr d When Submitted Properly Completed. Be S <br /> APPLICATION Sign The Application. <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> 4 <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> BROKER AND/OR PUBLIC POOLS, WATER SAMPLING IF VEHICLE INVOLVED, GIVE <br /> .ICCNSE AND/OR HEAL ESTATE INSPECTIONS Make <br /> 3TRATION <br /> I, ,BER POULTRY RANCHES AND KENNELS Lic. NO. <br /> -, MISCELLANEOUS SERVICES <br /> Regist. No. <br /> f Application Date 7/26/88 Color <br /> Business/Name To Appear On Permit <br /> oTYpe Permit/Service Requested: <br /> Applicant Name Applied GeoSystems <br /> California 95826 Address 4191-E Power Inn <br /> u Business Telephone No. Road Sacramento <br /> 'aPropertyLocation/A dress Benjamin (916)452-2901 <br /> `Property owner She Oil Company Holt Drive Stockton CA Emergency Telephone No. <br /> LOperator's Name Same as above. Address — U. Box 4023 <br /> T• FOOD ESTABLISHMENTS 9 C <br /> Address oncord CA 94524 <br /> Total Building Sq. Foota a <br /> FOOD MARKET RETAIL ❑ g Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ <br /> E3 FOOD PROCESSING PLANT El COMMISSARY <br /> MARKET WHOLESALE ❑ <br /> ❑ ROADSIDE FOOD STAND ❑ COMMISSARY ❑ ICE PLANT MEAT MARKET <br /> LIQUOR STORE ❑ <br /> ❑ CONFECTIONARY STORE ❑ BAR ❑ BAKERY <br /> E3 VENDING MACHINES/No. of FOOD SALVAGER ❑ FOOD DEMONSTRATION O ITINERANT RESTAURANT <br /> No. of Field Employees ❑ MOBILE FOOD PREP. UNIT FOOD VENDOR <br /> ❑ FOOD CROP HARVESTING/ <br /> ALL APPLICANTS: Total Employees IncludingVENDING VEHICLE <br /> Z• HOUSING 0perators— <br /> ❑ HOTEL/MOTEL/No. Of Units <br /> C3MOBILE HOME PARK/No. of Spaces C3CERTIFICATE OF OCCUPANCY PAYMENT'D <br /> 3, WATER QUALITY ❑ WATER SAMPLE Bacterial) ❑ RECEIVE(� <br /> ❑ PUBLIC WATER SYSTEM C3 ( CHEMICAL <br /> NO. OF PUBLIC SERVED (ConnectionsWATER <br /> WATER SUPPLY ❑ WATER HAULER JUL 28 1988 <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ �J <br /> 5. VECTOR CONTROL ❑ WADING POOL ❑ NATURAL BATHIf GNVIRO 'MENTAL HEALTH <br /> POULTRY FARM/Maximum No. of Birds — <br /> :ENNEL/Runways /Animal Population No. MIT�$ERVICE$ <br /> Sewage Disposal Method -�__No.Of Confining Cages <br /> Solid Waste Disposal Method -- - - -- <br /> Water Supply Source <br /> Am sle <br /> B• ® CONSULTATION FEE Pre liminar environmental assessment DisposalShellethod <br /> Service Station AGS Jo <br /> �• ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE 038037 <br /> REQUEST: Water Well Inspection Sample❑ <br /> Sewage System Inspection El Address Company <br /> Addres <br /> Escrow No. s <br /> Tele. No, <br /> Seller <br /> Telephone No. Seller Address <br /> �— 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, an ules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Title Project Geologist <br /> Date_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑January 1 8 Received By January 37 <br /> BASE ❑ July 1 a q¢ceivetl MI July 31 <br /> E%PLANATION BILLING REMITTANCE <br /> DATE DATE REMITTED AMOUNTDUE REMIT <br /> FEE TTED CHECKED <br /> LESS AMOUNT <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Oat Receipt No <br /> Permit <br /> APPLICANT RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES No I ce Date — _ <br /> MaVetl Delivered <br /> 1601 E.HAZELTON AVE.,P.O.BOK 2009 STOCKTON,CA 95201 <br />