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Applications Will Be Proc When Submitted Properly Completed. Be Sure Ign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGIN 110101 FOOD ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/OR Make —. <br /> CONTRACTOR AND/OR PUBLIC POOLS. SPECTWATER SAMPLING <br /> BROKER AND/OA REAL ESTATE INSPECTIONS LiC. NO. --------- <br /> ROKEEAND/OR Please See attached POULTRY RANCHES AND KENNELS Regist. No. ------- <br /> 3TRATION MISCELLANEOUS SERVICES Color — <br /> I. .BER <br /> f Application Date hep Le'mh2r9->--19.8 <br /> 83usiness/Name To Appear On Permit _Roek Bros. Balbi <br /> ,Type Permit/Service Requested: Review of ReRQTt for B:.Se_11SSeSSMient_—/� <br /> : Roek Bros. c/o Neumiller & BeardS�eAddress Drawer-M., kton c^1 if rnia, 95201 <br /> ,Applicant Name — 700 Emergency Telephone No. <br /> B _ Business Telephone No._2D9-X94$- g y p <br /> J <br /> Q.Property Location/Address p 0 BoX 30038 Stockton Calif. , 95213-0038 . <br /> aProperty Owner—$4ek—fro°• - --- Address <br /> LOperator'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 I '` <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) 11 CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER L` <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATING 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 /> Anim I Was[{Di`posal Method <br /> Water Supply Source <br /> 6. EKCONSULTATION T jitle <br /> 7. ❑ .PLAN CHECKING F8. REAL ESTATEn[(� Orf p0REQUEST: Water Well Inspection❑ Sample❑ Company _ ----yyp- -r��E3oo <br /> Sewage System Inspection ❑ Address <br /> Escrow No. ENVIRONMENTAL HEALTH <br /> Seller _ Seller Address <br /> Telephone No.— Seller Agent Name --..-- <br /> I Service Request For Date — <br /> \1 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 ws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Title Attorney Date 9/12/88 _. <br /> FOR DEPARTMENT USE ONLY <br /> Fee P IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑July 1 &Received ByEMI <br /> eceiv dByI July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE ^,6D I ' '`� - / .: i-uC I R 3T DUE ACC UNTS30 <br /> LESS DAY5 _ROM BIL - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 12 12 88 <br /> OTHER <br /> 0 . <br /> an <br /> Date Receipt No. Permit N Iss c Date liv <br /> Mailed Deered <br /> Received by 1601 E.HAZELTON AVE.,P.O.9os M09 STOCKTON.CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />