Laserfiche WebLink
Applications Will Be P—essed When Submitted Properly Completed. Be I -e To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND,OR PUBLIC POOLS.WATER SAMPLING — <br /> BROKER AND OR REAL ESTATE INSPECTIONS LIC. NO. <br /> Ir'FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> 't. .dER _ Color .--- ------------- <br /> Application Date _____ -_.__.. .._-__.__ .______ Business/Name To Appear On Permit <br /> u,Type Permit/Service Requested: <br /> a Applicant Name _-__IIltra_.Mart_ _—__._._—_—____ __ Address 2185 E.—Fr-emont—St, <br /> U <br /> Business Telephone No. __—____—_._.________-__ Emergency Telephone No. <br /> aProperty Location/Address __--2185--E__-Fremon-t--Fremont -eet-,--Stockton-- --- <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 ❑ 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 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 /> 5. 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 <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 /> 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. <br /> APPLICANT'S SIGNATURE X __ Title -- Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑_PER SITE _ ❑ EACH ❑_January 1 d Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE $35 .00 Inspection 9-21-9 <br /> LESS <br /> PRORATION <br /> PLUS ---- -- — <br /> PENALTY $3.50_- Penalty_ 10-22-90 <br /> OTHER —_ $3.85 Penalty 11-30-90 3rd Billin $42.35 <br /> OTHER <br /> RucL•wed by Date .iece.pt Nu Peruul No Iss—ace Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />