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Applications WIII Be Fired When Submitted Properly Completed. Be SSign The Application. <br /> is APPLICATION u To <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> NEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> .ICANTS AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> !TRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> )KER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> .dER - Color <br /> Application Date J l Y 20, -988 Business/Name To Appear On Permit — tom?'..CSS tQn S Caves n qja-r_Assn . <br /> ,Type Permit/Service Requested: Samp.if <br /> 5ApplicantName E�tocktcn Scavenger Assn , Address 1240 Navy Pr. f7tockton Ca 95206 <br /> a Business Telephone No. 946-5711 Emergency Telephone No, 948-4071— <br /> Property <br /> 48-4071Property Location/Address 1240 Navy Dr S toctlkon Ca 95206 <br /> a �tockkon Scavenqer Assn. 1240 Navy Dr Stoctkon Ca 95206 <br /> a Property Owner Address <br /> [Operator's Name StO(ct<bon f'cav,71nrrr'r Assn. Address 1240 clave Dr Ca 95206 <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 /> El 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 sample & analyses plan July 15, 1988 for Stockton Scavengipr by E is <br /> 7. ❑ PLAN CHECKING FEE mco <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, and rules and regulations of the San Joaquin Local Health District, <br /> /jam _ r7vr,l /'I r �vlU�o Q <br /> APPLICANT'S SIGNATURE X Lir-�'• - ' Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE — <br /> LESS �l <br /> PRORATION <br /> -LUS <br /> ENALTY <br /> Adak <br /> R <br /> 4 y , <br /> 7y Date P1 N. <br /> Permit No Iss ate Mailed Delivered <br /> -iCANT—RETURN ALL COPIES TO: ENVI ENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON•CA 95209 <br />