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Applications.Will Be,Processed-Wh9"abmitted Properly Completed. Be Sure To Sign The Application. <br /> i t� x ,I APPLICATION <br /> ENGINEER'S AND/OR <br /> �,JIRONMENTAL HEALTH PERMIT/SER. S GENERAL <br /> I �� a` <br /> APPLICANTS AND/OR JAN 21 1981 FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> LICENSE AND/OR I- � POULTRY RANCHES AND KENNELS <br /> REGISTRATION SAN J lVOIN I"MISGELLANEOUS <br /> SERVICES Regist. No. <br /> NUMBER _ I-IFAI TH DISTRICT Color <br /> Application Date Business/Name To Appear On Permit Best Ferti T i ler <br /> FType Permit/Service Requested: <br /> zApplicant Name Occidental Chemical Address P-0. Box IRS. l athrop <br /> JL J Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 2715 Lc 0SP, I athrop <br /> `Property Owner _ Address <br /> L Operator'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 ❑ fTINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ 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 SYS ❑ 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 /> ❑ KENNEL/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 ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <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 repared this pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an s and re ' lations of the San Joaquin Local Health District. <br /> Manager, Environment, <br /> APPLICANT'S SIGNATUR X t.t Title Health R Cafe� Date 1/20/81 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUAL7 d 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �7 <br /> O �t AMOUNT <br /> FEE $70.00 1981 /16/81 }Due 2 16 81 $70.00 X <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> –All 7/7��LY 6661 6y 2—-7 81 <br /> Receaved 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 />