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r Applications Will Be r ssed When Submitted Properly Completed. Be To Sign The Application. <br /> \%V' APPLICATION ... <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ,ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND,OR FOOD ESTABLISHMENTS.HOUSING flake <br /> CONTRACTOR AND OR PUBLIC POOLS.WATER SAMPLING <br /> 9ROKER AND OR REAL ESTATE INSPECTIONS LIc No <br /> ,rFNSE AND.OR POULTRY RANCHES AND KENNELS <br /> 3TRATION 137422 MISCELLANEOUS SERVICES Reglst No <br /> I. .9ER Color <br /> 10/31/89 IT Torporation <br /> -Application Date Business/Name To Appear On Permit <br /> u,Type Permit/Service Requested: - Soil Boring/ Monitoring Well Installation <br /> a Applicant Name IT Corporation` _ Address-- 4575 Pacheco Blvd_, Martinez, CA. 94553 <br /> (415 372-9100 <br /> ) (800) 326-4826 <br /> Business Telephone No. _.-- Emergency Telephone No. _._ _ <br /> ', Property Location/Address 1403 Country Club Boulevard; Stockton CA. <br /> Property Owner BP Oil Address 2868 Prospect Park Dr.#360; Sacramento, CA. <br /> BP Oil - -- -- -- same — — 95670 <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 /> ❑ HOTEL/MOTEL/No. of Units __.._ ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces _ <br /> 3. WATER OUALITY ❑ 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 /> .ENNEL/Runways _— /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method — <br /> Solid Waste Disposal Method <br /> Water Supply Source __ .__——J, / Animal Was sposal Method <br /> 6. O CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company-_ _W___________�_ <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 th_qSan Joaquin Local Health District. <br /> C /� <br /> APPLICANT'S SIGNATURE X Title - Date ` O 3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE j EXPLANATION BILLING REMITTANCE I $ AMOUNT DUE CHECKED <br /> DATE DATE I REMITTED AMOUNT <br /> FEE <br /> F F-tis 1 <br /> I'Ht)HATIDN _�.. <br /> VI ll6 <br /> IN <br /> NAF TY <br /> - <br /> I <br /> f Ilrr r wr rl by I l.itr lip—pt No I'rrmit No –Issuance Date Matted TDelivered i <br /> n PP1.ICANT RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT,SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 — <br />