Laserfiche WebLink
Applications Will Be P• used When Submitted Properly Completed. Be Sy -t, To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> -- APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING 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 Regisl. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I . .dEH _ - - -- Color -- <br /> Application DateNGvember 16 , 1988 Business/Name To Appear On Permitome_.hni—C-2IIS_truc Y ! on - <br /> Type Permit/Service Requested: Review Soil and Ground Watex As essmPnt_Work Plan (Nnnemhar 1 (T, 1 4liR ) <br /> QApplicant Name Nome_ _l_lini Construction Address93_LWest Charter—W3� 4tnrktnn ,_CA <br /> _ - Business Telephone No. ( 209 ) 466-5 W_Gk Emergency Telephone No. ZOY 'SF !eSS'98,3 <br /> I, Property Location/Address 1045 West Charter Way , Stockton _CA <br /> J Property Owner - - - t� , trop Z' Address -939 West--Char-tar-Way, $YJDckt on i CA <br /> Sonny Shi wash <br /> - [ Operator's Name Y P Address Same <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 /> ❑ 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 Review Soil and Ground Water Assessment Work Plan (November 16 1988 ) <br /> 7, ❑ PLAN CHECKING FEE $ 35 00 Review - REQUESTING RUSH REVIEW <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection [] 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 /> pc d^eriz; i-L <br /> APPLICANT'S SIGNATURE X ip �'"'�-�s-s. Title �" �T`�"Y'� Date RZ ' 3U - 4J $ <br /> FOR DEPARTMENT USE ONLY <br /> Fee I6 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 6 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT WE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT _ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ! PENALTY <br /> I ! OTHER <br /> OTHER <br /> Rcglved by / Date , /�Rrecu l No. Permit No. Issuance Date Mailed Delivered <br /> //APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA SS201 <br />