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Applications Will Be Proed When Submitted Properly Completed. Be S*O Sign The Application. <br /> APPLICATION <br /> �. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGVNEER'S AND/OR <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING V VED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Oe <br /> BROKER AND/OR REAL ESTATE INSPECTIONSIrENSE AND/OR POULTRY RANCHES ANO KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES st. No. <br /> I, aER .---— ----- Color <br /> [Application Date Business/Name To A —North County Landfill <br /> Appear On Permit _ <br /> G*Type Permit/Service Requested: <br /> `Applicant Name a J0a-q-Ui n C.oU-ntV---Publ i c forks Address 1810 E. Hazelton Ave. , Stkn <br /> U <br /> a Business Telephone No. Emergency Telephone No. <br /> —----— <br /> aProperty Location/Address 17916._E_ Harney/ Lane, Lodi._ <br /> aProperty Owner _ Address _ <br /> [Operator's Name 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 /> .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 /> 6. M CONSULTATION FEE Solid_ 1�Iasto _ Appl. <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection El 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE , /89 -- <br /> 9/27/89 $500 $60.00 <br /> LESS <br /> PRORATION S e attached <br /> PLUS S W� <br /> PENALTY PENALI <br /> OTHER _AVS F OM BILLING DATE. 30 <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 95201 <br />