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Applications Will Be Pro^-Ssed When Submitted Properly Completed. Be Sur-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 Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES -- <br /> I, .AER ----------------- Color ---- - <br /> (Application Date January 19, 1989 Business/Name To Appear On Permit <br /> ,,Type Permit/Service Requested:Review of Soil and Ground Water Assessment Report <br /> `Applicant Name Resource Development Address 41 _W_ Yokuts Avenue, Suite 125, Stockton, CA <br /> M Business Telephone No. (209) 951-5-737- Emergency Telephone No. Same <br /> IL Property Location/Address Weston Ranch Parcels, Stockton, CA <br /> <Property Owner R 2 9 9 111'"" '�---''- - ! yQ.1j_GbMr g-&—k -WAddress 41 -Tel. Yokut-& Ave_ , Stti to 19 5_,_-Sto-c1CtAIL,_ CA <br /> LOperator's Name Reacurc_e Develapment Address 41__W_YAku-ts-Ava.--,--Suite_125, Stockton,- CA.- <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 /> .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. ED CONSULTATION FEE Review Soil and Ground Water Assessment Re ortfor i� <br /> 7. ❑ PLAN CHECKING FEE $ 35 Report Review ated January 12, <br /> 1989 <br /> 8. 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 law cJ rules and re lation�f thf S�uin Local Health District. <br /> f � Titley/D r /-/ Date <br /> APPLICANT'S SIGNATURE. �-� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE 4WIt <br /> rOI <br /> ! <br /> FEE � r� /PQ�/ �S c I Y <br /> LESSs. <br /> PRORATION YZp <br /> PLUS PF F <br /> PENALTY C <br /> OTHER SFR yF <br /> .S <br /> OTHER <br /> fiteceived by 7— Date Receipt 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 95201 <br />