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�i <br /> Applications WI* ssed When Submitted Properly.Completed. Be To Sign The Application. <br /> k" APPLICATION - <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINIIER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING PAYMEN'Pake <br /> BROKER AND/OR REAL ESTATE INSPECTIONSRECEIVEaic. No. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES fj E 14 <br /> SAN JOAQUIN C01,`NTY <br /> I dEA <br /> Application Date Business/Name To A PUBLIC <br /> Appear On Permit <br /> o;Type Permit/Service Requested:— - -------- .._-- -- —_----___-- ENVIRONMEINTAL HEALS _ <br /> a Applicant Name Foothill Sanitary Landfill , INc, _- Address- _P ._0 Box 1461, Stkn 5201 <br /> — — -- — -- <br /> _ ___—_________ _ —_ Business Telephone No.__.—_—_.__ —_.____--._ Emergency Telephone No. <br /> QProperty Location/Address __ 6484 Waverly Rd. , Linden <br /> aProperty Owner._.--__—.__.__ _- 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 13,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 /> 11 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 /> S. 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. ❑ CONSULTATION FEE Solid Waste <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 /> SellerSeller Address __-- <br /> Telephone No. —_—__ _ Seller Agent Name _____- <br /> Service Request For Date — ---- -------- -------- --- <br /> 1 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 /> t <br /> APPLICANT'S SIGNATURE X --_ TitleA A Date _ <br /> FOR DEPARTMENT USE ON Y <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 CHECKED <br /> DATE DATE REMITT <br /> _ AMOUNT <br /> FEE ----$1050.00 see attached 8/24/90 $1050.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dae r Receipt No. Permit No. Issuance DateMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -- <br />