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' Applications Will Be Prr Seed When Submitted Properly Completed. Be Sv- To Sign The Application. <br /> �I APPLICATION `J <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,MOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> if"NSE AND/OR POULTRY RANCHES AND KENNELS <br /> RATION MISCELLANEOUS SERVICES Regist. No. <br /> IcR _ _ Color <br /> Application Date APS'it 11-2" .. 989 Business/Name To Appear On Permit Ge or a Geme llos I <br /> Type Permit/Service Requested: Re,:e�SCBlyRtlon Off' gasOlne tank-site-s <br /> Illt Applicant Name Address- 09W. Hwy 12 - Lodi CA. C)5942 <br /> U <br /> Business Telephone No. (209)369-1132. Emergency Telephone No. fie- -- - <br /> ILProperty Location/Address s']4.4� ��_� -_�.� LOs33i__ �. ` _._t',n'i^TlA7+ of DRVY-jjea Rr. Hv�r <br /> `Property Owner .._..-G'_e fll g8_.Geme 3-1 os# " Address .. Ume .$i."Lib OVe <br /> L Operator's Name Address -SSMA A S above. <br /> t. 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 /> Cl 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 11 SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5 'ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r`l11I,,..:NNEL/Runways _— /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method _ <br /> Solid Waste Disposal Method <br /> Water C ION,S�pply Source Animal Waste Disposal Method <br /> 6. CONSULTATFEE"'f�--!rr <br /> IF. Cl PLAN CHECKING FEE <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 laws, d rules and ulations of the San Joaquin Local Health District. <br /> IZA <br /> APPLICANT'S SIGNATURE X __. Title �QZ' Date A 11, 1989 <br /> CX FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> -_DATE DATE REMITTED AMOUNT <br /> �SFEE - <br /> LESS ` Cn <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.Box 2009 STOCKTON,CA 95201 <br />