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w Applications Will Be Oessed When Submitted Properly Completed. Be*To Sign The A plication. <br /> APPLICATION <br /> ENGINEER'S AND/OR FLE' <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING INV VED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS — <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. AER __ <br /> COIOf <br /> Application Date Business/Name To Appear On Permit -------..._.. ------------- <br /> F Type Permit/Service Requested: _ <br /> `Applicant Name STOCKTON SCAVENGER ASSOC. _ Address P. 0. Box 1747, STOCKTON, CA9_52 T --- <br /> n Business Telephone No. Emergency Telephone No. <br /> `Property Location/Address__ <br /> 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 /> r :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. XX CONSULTATION FEE Solid Waste P _rmi t <br /> 1. ❑ .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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT. <br /> LESS PEN LTIES WILL E 23 18 $525.00 /' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER NOTE - MAK CHECKS PA ABLE TO PU LIC HE LT <br /> OTHER <br />`Received by Date Receipt No Permit No. Issuance Date Mailed <br /> Delivered <br /> '� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES pan.c <br />