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Applications Will Be Pd When Submitted Properly Completed. Be $Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGAEEI'S AND!OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR `I PUBLIC POOLS. WATER SAMPLING Make _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATICN MISCELLANEOUS SERVICES Regist. No, <br /> dER <br /> Color <br /> Application Date -MaY 24 1989 _ Business/Name To Appear On Permit -Jim ThoUe Oil <br /> wType Permit/Service Requested: Water Quality — <br /> UApplicant Name Staal, Gardner & Dunne, Inc._ Address 121 North Fir St. , Suite F.Ventura, Ca.93001 <br /> –_5556 <br /> CIL Business Telephone No 805)653 _. Emergency Telephone Na(805)653-5556 <br /> LProperty Location/Address - 2402 North Pacific Avenue <br /> L -California Fuels <br /> — __ — __ — — — AddressP.O.-- Box 1207_,_StoCkton_,C�a._9520l <br /> Property owner California FuelsAddress <br /> operator's Name . P.O. Box 1207 Stockton,Ca. 952QI <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 /> 11PUBLIC WATER SYSTEM 99 SURFACE WATER SUPPLY ❑ WATER HAULER Conduct Soil Vapor Survey to <br /> NO. OF PUBLIC SERVED (Connections) — evaluate for soil contamination. <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 >2- u _ <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Staal Gardner & D�Lnne, Inc. <br /> -�7 Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: © .ANNUALLY PER UNIT . ❑ PER SITE ❑ EACH ❑ January/ &Received By January 31 ❑ July 1 B Received By July 31 <br /> r1 KILLING, REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE —1 , o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> UU <br /> 92 1 <br /> OTHER <br /> OTHER <br /> - LS _ <br /> Received by Date <br /> ipt No C5_*Permll No Iss ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/BERYICES 1601 E.HAN AVE.,P.O.Box 2009 STOCKTON.CA <br />