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Applications Will Be ssed When Submitted Properly Completed. BeTo Sign The Application. <br /> APPLICATION it <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .DENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> 1. BER Color <br /> rApplication Date_ Business/Name To Appear On Permit Stockton Scavenger Association <br /> oType Permit/Service Requested: <br /> `Applicant Name Stockton Scavenger Assn. _ Address P. 0. pox 1747, Stockton 95201 <br /> — Business Telephone No. Emergency Telephone No. <br /> `Property Location/Address _1240 Navy Dr , Stockton <br /> `Property 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. 93 CONSULTATION FEE - Solid Waste <br /> to - <br /> T. ❑ 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, 51,!Y' rules and regulations of t San Joaquin Local Health District. <br /> =l <br /> APPLICANT'S SIGNATUREX 1f � Title Date <br /> FOR DEPARTMENT ULA <br /> LYIFee IS DUe: 1:1ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ I ived By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTA REMIT <br /> BASE EXPLANATION CHECKED <br /> DATE p��p�r� ED AMOUNT DUE AMOUNT <br /> FEE $560.00 See Attached 3/5/9Q-/VL,0�e N✓�� �� $560.00 <br /> LESS <br /> PRORATION q7�1 / Al <br /> PLUS <br /> PENALTY PENALTIM WILL 9E APPLIED TO PAS DUE ACC � <br /> NT ;` , <br /> of <br /> OTHER H ATE. :,;;•,�,/ <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 /> i <br />