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Applications Will Be Pro*d When Submitted Properly Completed. Be Sur n The Application. <br /> APPLICATION <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 TER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES RegiSY. NO. <br /> I. .aER __ Color <br /> [Application Date Business/Name To Appear On Permit <br /> oType Permit/Service Requested: ° <br /> -Q Applicant Name—Cali for ni a Waste RemoVaT System Address 0. x 9 odi 95241 <br /> a — Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 1333 E. Turner Rd. , Lodi <br /> e Property Owner_ Address <br /> -Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT 0 FOOD MARKET RETAIL 11 FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> FOOD PROCESSING PLANT ❑ COMMISSARY 0 ICE PLANT ❑ BAKERY <br /> ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 BAR ❑ ITINERANT RESTAURANT` <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER 11 FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of 0 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 0 WATER SAMPLE (Bacterial) 0 CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY 11 NATER HAULER <br /> NO. OF PUBLIC SERVED(Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 11 WADING POOL ❑ NATURAL <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No. of Confining e <br /> Sewage Disposal Method JC3An,I,i I, <br /> Solid Waste Disposal Method E VIA �E� <br /> Water Supply Source Animal Waste Disposal Method TAS 1 fl 11«(; S <br /> ti. ❑ CONSULTATION FEE L4VISION <br /> 7. ❑ .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 repa ed this a It tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rul nd o oft an J quin Local Health Di ict. <br /> APPLICANT'S SIGNATURE X 0 Title <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $490.00 See Attache 2/1/90 $490.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - IED TO PAST <br /> . <br /> OTHER <br /> 1 -(-�,0 <br /> Received by Date Receipt No. Permit No. lasuonco mto Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 10019,HAZ9LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />