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Applications Will Be Proce i When Submitted Properly Completed. Be Sure Sign The Application. <br /> • APPLICATION II <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lie. No. <br /> Ir'ENSE AND/OR POULTRY RANCHES AND KENNELS RIst. No. <br /> 3TRATION CE 25362 MISCELLANEOUS SERVICES Regist. ---- - <br /> 1, .dER _- _ Color <br /> IApplication Date 7112/88 _ Business/Name To Appear On Permit <br /> FType Permit/Service Requested: Work Plan Review <br /> zA //cant Name Kaldveer Associates, Inc. Aaaress -- _ <br /> `o pp --- .�. _Roland WaY,_Oakland_ CA 94621 <br /> CL <br /> Business Telephone No.j 415) 568-40QL� Emergency Telephone No. <br /> a Property Location/Address 2010 West_Fremont,_Stoc_jgon,_C A _ <br /> gPropertyOwner____Charles H. Bloom Company• Inc. - Address 2010 West Fremont.-.Stnck nn, CA <br /> Operator's Name -Same- Address1. FOOD 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 ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of - ---- ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees M��•� <br /> ALL APPLICANTS: Total Employees Including Operators r� Q p►Y EjV F-02. HOUSING REG y <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> C3i{{t <br /> MOBILE HOME PARK/No. of Spaces .-_. .. i3Ul. <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) I CHEMICAL HAI-�H <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER Nv,RQ�yMENTAI. <br /> NO. OF PUBLIC SERVED (Connections)— _---__.._._"-_.—. Q�(LM}�Isuoj Os <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM//Maximum No. of Birdsr =ql HEALTH <br /> r :ENNEL/Runways /Animal Population No. No. of Confining Cages IvV1� <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ® PLAN CHECKING FEE Reid-P- r�ork Plod, $3 h-r. KE595-5 (projac-t <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 rules d UI ns ofhe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XI TitleViCe -Pres. En eerie Date Ly 12, 1988 <br /> F R DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY El PER UNIT 1_1PE E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ RE <br /> MIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - - - - — � <br /> Re wed by Da- 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 20D9 STOCKTON,CA 95201 <br />