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Applications Will Be Peased When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPWCANT'S AND/OR F000 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 /> STRATION 512268 MISCELLANEOUS SERVICES g <br /> I. .BER Color <br /> [Application Date 6-5-89 Business/Name To Appear On Permit Spectrum Expl. , Clayton Envir. Cons. <br /> MType Permit/Service Requested: 4-8 'depth and 1-10 depth soil borings, backfill inspection <br /> i Applicant NameJim Rleinfelder Address2825 E. Myrtle St. , Stockton, CA <br /> 95205209-465-8712 911 <br /> a Business Telephone No. Emergency Telephone No. <br /> aProperty Location/Address540 W. Scotts Ave. , Stockton, CA <br /> 'PropertyOwner Ms. Sheridan Randolph _ AddressP•O.Box 23731, Oakland, CA. 94623 <br /> Operator's Name not in operation 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 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 /> WaterSupply Source __ Animal Waste Disposal Method <br /> 6. K CONSULTATION FEE •ls • tl0 -- <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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, rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XTitle 1&47 Dated <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �llj on <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> loS— <br /> Received byDater 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 85201 <br />