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Applications Will Be Pr�ed When Submitted Properly Completed. Be S 0 Sign The Application. <br /> UOaY a�hl:�c�u�., APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> ENGINEER'S AND ((( IF VEHICLE INVOLVED, GIVE <br /> -�' \.�� <br /> CONTRACTOR ANDiOR PUBLIC POOLS.WATER SAMPLING Make - -_- _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No, <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEOUS SERVICES Regist. No. - <br /> I. dER <br /> Color - .-- - - - <br /> rApplication <br /> Date 11^=16`_90 _—_ Business/Name To Appear On Permit <br /> Type Perm it/Se rvice,Requested: FILE REVIEVRECORD RELEASE <br /> a Applicant Name -_ SIERRA ENVIRONMENTAL SERVICE§WrJWSLIE A CLEMENT P n B0 254i^ <br /> -- -- - - <br /> - - <br /> _ MARTINEZ= CA U45�18bsiness Telephone No. _ Emergency Telephone No. <br /> a Property Location/Address 700 DOUGLA6111 6N k PACIFIC AVE' bUl L NCULIV C11 TE <br /> -- --- <br /> J Property Owner -_ _ ___ Address - <br /> -- - -- <br /> 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 ❑ -A H ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION a7 I G REMITTANCE $ REMIT <br /> —DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - — - _ AMOUNT <br /> FEE $50.()0 FIL ' 'REVIEW/ ECUIti1 RELEASE— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 2009 STOCKTON,CA 95201 ..-- <br />