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Applications Will Be P ssed When Submitted Properly Completed. Be To Sign The Application. APPLICATION ,, ,d ENVIRONMENTAL HEALTH PERMIT/SERVICES 3� r ENGINE". R AP0PLICAN, NDIOR CONTRACTOR AND/OR BRLKER AND/OR FOOD ESTABLISHMENTS. HOUSING PUBLIC POOLS. WATER SAMPLING REAL ESTATE INSPECTIONS - IF VEHICLE INVOLVED, GIVE Make Lic. No. irFNSE AND/OR 3TRATION I + 'BER ------- Unit II_ POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES REMIT CHECKED AMOUNT Regist. No. Color ---------------- - Application Date _--_ _ — Business/Name To Appear On Permit _—.Foothill Landfill --- HType Permit/Service Requested:_ —.__ —_.--__-----__----.__-- Applicant Name Fnnthi 1 1 T anclfi l l /S �o ____ Address F fQ�- ion l - lop U�t�CA 95201 U _ Pohl i c_Wnrkc __—_ _ Business Telephone No. Emergency Telephone No. 6 a Property Location/Address _ Property Owner San JOaCI11in CoLmty _ —___ Address P.O. Box 1810, Stockton, CA 95201 L 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 ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING (1AACHINES/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 ❑ 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 — .ENNEL/Runways -- /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method Water Supply Source _.._ Animal Waste Disposal Method 6. IV CONSULTATION FEE Sol id WagtP Permit Review — Overtime 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection 13 Sample Title Company Sewage System Inspection ❑ Address Tele. No. Escrow No. Seller Seiler Address Telephone No. -- Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. 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 BASE BILLING EXPLANATION DATE REMITTANCE DATE $ REMITTED AMOUNT DUE REMIT CHECKED AMOUNT FEE $106.00 see attached 12/28/9C $106.00 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No Permit No. Issuance Date Mailed Delivered