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Applications Will Be P cessed When Submitted Properly Completed. B To Sign The Application. APPLICATION ' ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND,OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND�OR FOOD ESTABLISHMENTS. HOUSING CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING Make BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. WENSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION Unit II MISCELLANEOUS SERVICES Regist. No I. BER Color .-- __-- ---- -__ Application Date_ ___ Business/Name To Appear On Permit North CountyLandfill Type Permit/Service Requested: _ ____ __. -_ -___ _ _ e Applicant Name North. County 1.ar1C1Ml/S..j Co_. _ Address P.O. BOX -1810.} Stockton,_ CA 95201_- _ 0 D --Public Works ____ ____ Business Telephone No. _._ __ ______ ___ - Emergency Telephone No. 'a Property Location/Address North._CrnoMty--i,andflll---- aProperty Owner _sail Joa in ---Court __ __ Address P.0 1810, Stockton, CA_952_ Operator's Name - — - ---- -- -- —------ Address ---- ----- ---- --- 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY C❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units __—_ ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 0 PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r :ENNEL/Runways _ __ ____.____ /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water Supply Source _ Animal Waste Disposal Mthod _ 6. LR CONSULTATION FEE solid Wast_ e=_Po_s_tclosU_Y_e_ Plan Review — PreTimiilary 7. ❑ PLAN CHECKING FEE -- __-_- 6. REAL ESTATE REQUEST: Water Well. Inspection[] Sample❑ Title Company Sewage System Inspection ❑ Address _____.______.__ ___ , Tele. No. Escrow No. _- Seller __._._ _ ___ ____ _____ Seller Address ° - 77 Telephone No _ __ ____ Seller Agent Name Service Request For Date —---------------__..__--_—_-_ - — "_fit T__—__--- --- I hereby certify that I have prepared this application and that the work will be'done in ACcAapce with San,Joaquin County ordinances, state laws. *r APPLICANT'S SIGNATURE X Title — Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 FEE LESS PRORAI PLUS PENALT OTHER OTHER Received by Date Receipt No Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE REMIT CHECKED GATE DATE REMITTED AMOUNT $3,696,_75 see attached 12/28/_0 $3,696.75 ION _— Y �, rC°t1r P.FPDrIF'f Received by Date Receipt No Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201