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Applications WIII Be Prod When Submitted Properly Completed. Be Sur 4Sign The Application. <br /> • APPLICATION <br /> ` ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICL , GIVE <br /> APPLICANT'S AND/OR 1,000 ESTABLISHMENTS. HOUSING Make - -- <br /> TRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING <br /> CIWER AND/OR HEAL ESTATE INSPECTIONS <br /> SE ANC,OR please see attached POULTRY RANCHES AND KENNELS <br /> 1TRATION MISCELLANEOUS SERVICES <br /> I. .aER <br /> f Application Date_.Sep-teIDher_-4,--L9.883usiness/Name To Appear On Permit Roek Bros,/Balb &-.Chang_ <br /> „Type Permit/Service Requested:-ReyieW-_0_f Report_jox- Site_Assessment- ...... -_— -- -- - <br /> a Applicant Name RQ-ek Bros.-QLQ__N_eum-i1l_er &L-Bga.rdslee Address Drawer ?_0,__S_tocktDD-,__Lalif.4sn7ia.-45201 ..__ <br /> J <br /> Business Telephone No._Z04L948-8200_—_ Emergency Telephone No. ------- <br /> ,Property Location/Address_19 SO tth W]LlS.Qn Way,__._----.------------ ---- ---- <br /> <Property owner__._12Qek-Bros. _— _ ---_._ AddressP_e0_Box 3003y Stockton. Calif. . 95213-0038 <br /> (Operator's Name ..__N/A _-.__._- - ____-.___ _ 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 <br /> ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of --_ ❑ MOBILE FOOD PREP, UNIT 11VENDING 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 /> ECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> ECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds _-_-01VENNEL/Runways _-._.____ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method___._ --- --- -"--- <br /> Solid Waste Disposal Method --- -- -_- ----- <br /> Water Supply Source _ Anim I Waste Disposal Method --- <br /> 6. r6K CONSULTATION FEE Vi C'T �Yz L_' tt�Sl� '�� I-0 <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUESTWater 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 ws,, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Title Attorney Dale 9/12/88 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH —❑ January 1TReceived By January 31 0-July 1 A Received By July 31 <br /> -- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKEO <br /> DATE DATE REMITTED tAMOUNT <br /> - PF,; ,' T! /:' L 1,3 o <br /> EE H OM BILLING DATE. <br /> LESS — <br /> PLUS <br /> PENALTY p ---- —� <br /> OTHER cT I.}� 12 12 $8 _ <br /> OTHER <br /> Recurved 9Y Oale Receipt No Perrml Na clt9uaccT Date—mailed Delivered <br /> ___-____ .... a.sono KTOCKTON.CA 95201 <br />