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�• Appllcolions WIII Ba Processed When Submitted Property EIOmplPled. Be Sure D n The ADP Ice ion. <br /> APPLICATION /a <br /> E+ ,RONMENTAL HEALTH PERMIT/SER �yy n <br /> 7q�� INVOLVED, GIVE <br /> r.r FOOD E5TAalISHMENTS,MOUSING MSK - --- <br /> ,,;,,, c,rl ER PUBLIC POOLS.WATSAMPLING n,E' aQ <br /> RIAI ESTATI INSPECTIONS Fiy�� � Lis N --- <br /> + POULTRY RANCHES AND KENNELS - _ <br /> N <br /> MISCELLANEOUS SERVICES � MTFhIq G ! <br /> 5-26-88 _ _ Business'Na^me To Apper.r On Permit <br /> ..+ca it lrps <br /> Pe m :,ace Re u`s'eC. UnderQround_Storage_Tank Closure _ —_. --- <br /> North Cal Construction __. Address P• 0 Box 588, Stockton CA 95201 _ <br /> AOJ!.canl Nnme _...-- (209) <br /> Susmess Telephone No._--_ 465_5886-- Emergency Telephone No. ----- <br /> E'Ic'^e-ty Local-GnlAddress. _-_5400 Pacific Avenu,._SL_QckLon. CA__9590.Z_—. - <br /> �r.,, „_.,tMontgomery Wards —__—_ Address 5400 Pacific Avenue, Stockton, Ca 95207 _ <br /> -- - <br /> Address <br /> s Name <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footace Restaurant, Maximum Seating Capacity <br /> O RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PPOCESSING 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%Nc. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2 HOUSING <br /> 11HOTEL/MOTEL/No. of Units 11 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARKINo. 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 /> IF .ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste DISPOSa! Method_ <br /> Water Supply Source _— Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE I —. <br /> 7. �i PLAN CHECKING FEE 390.00 <br /> S. REAL ESTATE <br /> REOUEST: Water Well Inspection C1 Sample❑ Title Company_ - <br /> Sewage System Inspection ❑ Tele. No. - <br /> Escrow No. - <br /> Seller _.—.-- -- Seller Address <br /> Telephone No..------ Seller Agent Name <br /> Service Request For Dale — <br /> 1 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 off ttthhhee San Joaquin Local Health <br /> ,District. <br /> � - <br /> APFLIGAtJT'S SIGNAT UFlE X /Ls. <br /> T1Et��-(fib.^-=��1` Title Sd - -E'er Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANN'JAILY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jenua+y 1Ta Aeceivntl Fir JanuerY 31 ❑ July 1 6 Recery REMIT <br /> 31 <br /> — - — — BILLING REMITT A.NCE F AMOUNT DUE CHECKED <br /> pp5� FxPLANAT ION DATE DATE REMITTED AMOUNT_ <br /> FEL <br /> PPE I f l II.N _ � Y r'f /O _ <br /> - , <br /> - --- <br /> DTru R <br /> P n 1 N, tA,uence Da!e... MnIW M Denvney —.—. <br /> ncr n�•r„ I W' 'n” • wa �.,�+ flnf Y,nu UMM7+•- <br />