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Applications WIII Be Prr-.�ssed When Submitted Property Completed. Be Sure To Sign The Application, <br /> APPLICATION <br /> VIRONMENTAL HEALTH PERMIT/SERES M �� <br /> ENGINEER'SIOR IF VEHICLE INVOLVED, GIVE <br /> APPU' P_NT'S AND/DR FOOD ESTABLISHMENTS.HOUSING Make <br /> CON HACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> rBA60<ER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, AER Color <br /> (Application Date Jan. 26, 1989 Business/Name To Appear On Permit Fabricare <br /> ~Type Permit/Service Requested- Consultation <br /> `Applicant Name Fabricare Address_71LS—San_Jo.aquin—Street, Stnrktnn, CA <br /> Business Telephone No. 2D9) 465-578$ Emergency Telephone No,0213)731-3132_ <br /> a 711 S. San Joaquin Street, Stockton, CA <br /> a Property LocationlAddress 4 <br /> diProperty Owner Califonria Linen Rental Service, InCAddress 1667 W. Washin ton Blvd. , Los Angeles, CA <br /> -[_Operator's Name Robert E. DeTrano (General Mana er)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 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 /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE r <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method f <br /> Solid Waste Disposal Method <br /> Anima!Waste Disposal Method <br /> Water Supply Source <br /> 6. ff CONSULTATION FEE Contamination Assessment Workplan <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> ❑ ❑ Title Company <br /> REQUEST: Water Well Inspection Sample � Tele. No. <br /> Sewage System Inspection ❑ Address <br /> d Escrow No. <br /> } Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> i- 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 law nd rules reg tions of the San Joaquin Local Health District. <br /> r Title <br /> Date Jan. 26, 1989 <br /> APPLICANT'S SIGNATU <br /> FOR DEPARTMENT USE ONLY <br /> 31 <br /> REMIT <br /> ❑ EACH ❑ January t 8 Received 6y January 31 ❑ July 1 d Received By July <br /> Fee IS UU2: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 15• <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER q <br /> — \ Issuance Date Mailed Delivered <br /> Received by Date <br /> Receipt No. Permit No. <br /> ' 1601 E.HAZELTDN AVE..P.O.Box 2009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TM ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />