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Applications Will Be Pr ed When Submitted Properly Completed. Be Suaajo Sign The Application. <br /> APPLICATION 1 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENG&EER'S AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTHACTOR'AND/OR PUBLIC POOLS.WATER SAMPLING Make —._ _—..—_..__._.._.. ... <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> irFJNSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION Unit II MISCELLANEOUS SERVICES g <br /> I. .dER -------------- Color _ .. ----------- .. <br /> ('Application Date______—_.__ Business/Name To Appear On Permit -javelace Transfer Station <br /> Type Permit/Service Requested: _ _. <br /> QApplicantName Lovelace Transfer StatlOTl/SJ Co _ Address__P•0• BOX 1 , tOC tori, <br /> aDenr�f Public Works Bu$Inesg Telephone No. Emergency Telephone No. -- <br /> a Property Location/Address_ Lovelace Rd. , NJaT1tGCa <br /> a Property Owner__,5Miacuiri Qgm_t _ Address P.O. BOX , tOC 011, <br /> CA 95201 <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 a 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. M CONSULTATION FEE Solid W2ste - CUM Permit - Overtime <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 00 AMOUNT <br /> j FEE X5742.00 Se attached 12/28/90 ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />