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Applications Will Be Pssed When Submitted Properly Completed. Belo Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGIN€ER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S Al FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR Al PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> .ICENSE AND/OR POULTRY RANCHES AND KENNELS Regat. NO. - -- <br /> STRATION MISCELLANEOUS SERVICES - <br /> Color <br /> 1, .SER - _- <br /> (Application Date July 27, 1988 Business/Name To Appear On Permit _Fist Bay Municipal Utility District <br /> wType Permit/Service Requested: Subsurface Environmental - -ation workplan review <br /> a Applicant Name East Bay Municipal Utility Distric Address - 0. Box 24055, Oakland, CA 9462:. <br /> I Business Telephone No. �`'17 j 465-3700 Emergency Telephone No. (415)465 / <br /> Property Location/Address '1804 W Main <br /> Street, <br /> treet Stockton <br /> <Property Owner East Bay Municipal Utility District Address 1804 West blain Street, Stockton <br /> Operator's Name same Address same <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 11 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 r. <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 rul s and regulations of t e San Joaquin Local Health District. <br /> Manager of Wastewater 7/29/88 <br /> APPLICANT'S SIGNATURE X Title Date <br /> It <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLR UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Receivetl By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ivetl by � 1 No. Permil No. Issu ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVI ENTAL HEALTH PERMIT/SERVICES 1111 E.HAZ NAVE.,P.O.Boi 2009 9TOCKTON.CA 95]01 <br />