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Applications WIII Beesaed When Submitted Properly Completed. 13Ess'e To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> Cot 1 <br /> ENGINEER',—,4D/QR IF VEHICLE INVOLVED, GIVE <br /> APPLI 'S ANDIOR 1000 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 /> iTRATION MISCELLANEOUS SERVICES g <br /> I. .dER _ Color <br /> [Application Date Jan. 26, 1989 Business/Name To Appear On Permit Fabricare _ <br /> rnType Permit/Service Requested: Consultation <br /> Applicant Name Fabricare Address_711_S_. San i_Oaquin Street, Stnrktnn- CA <br /> d Business Telephone No. 209 465=5788 Emergency Telephone No.(2131731-3132 <br /> iProperty Location/Address 711 S. San Joaquin Street, Stockton, CA <br /> Property Owner Califonria Linen Rental Service, 1ncAddress 1667 W. Washington Blvd. , Los Angeles, CA <br /> -[Operator's Name Robert E. AeTrano (General Manager)Address 711 S. San Joaquin Street, San Joaquin, 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 f=ield 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 /> 0. � CONSULTATION FEE Contamination Assessment Workplan <br /> 7. ❑ .PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample 13 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 ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state la nd rules reg tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU grana Title Date Jan. 26, 1989 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> S. CFO 3'a u-0 <br /> LESS <br /> PFIORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 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 95204 �_f` <br />