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Applications Will Be Prr-+ssed When Submitted Properly Completed.Be S,, To Sign The Application. <br /> APPLICATION *.. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> GNGINEER'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 LIC. NO. <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> I. .aER Color <br /> ApplicationDate 7/6/88 Business/Name To Appear On Permit Goodwill Industries of San Joaquin Vallev_Inc <br /> [Application <br /> Type Permit/Service Requested: - <br /> ApplicentName Goodwill Industries Address 129 S Grant St Stn- orAtOn CA qS nq <br /> g Business Telephone No. 466-2311 Emergency Telephone No. I1FF-2141 U <br /> (Property Location/Address Same <br /> Property Owner Same Address <br /> - Operator's Name Same 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 ❑ 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 OUALITY ❑ 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 /> S. 521 CONSULTATION uKT LT*T+�� 1-29 S &9 kw1T Ca -.OsTiy�,K <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address PlAeM E <br /> Escrow No. RECEIVED <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name7 1988 <br /> „ <br /> Service Request For Date en���AC `{.I�p�j}{ <br /> I hereby certify that I have prepared this application and that the work will be done in accor"�tnBVfr� l4'SroIInEy <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. QnD,PEIUAIT SER I <br /> APPLICANT'S SIGNATURE X � - Tltle, �4 '" Date 7/�/�� <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY t4ER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec by ate WaxIiiiat0ipt No. Permit No. I eta Mailetl Deliveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box]009 STOCKTON.CA 95201 <br />