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40When 'Submitted Properly Completed. Be**gn The Application. <br /> Applications Will Be APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> � ----T�- <br /> EN+sINEER'S AND+OR FOOD ESTABLISHMENTS.HOUSING Make <br /> APpLiCANT'S AND+OR PUBLIC POOLS,WATER SAMPLING Lie. No. <br /> CONTRACTOR AND,OR REAL ESTATE INSPECTIONS Regist. No.-- --�- <br /> BPOKER AND/OR POULTRY RANCHES AND KERNELS <br /> I14FNSE ANDrOR MISCELLANEOUS SERVICES Color ---�J <br /> sTRATION <br /> 5. .dER <br /> II"Application Date � Business/flame To Appear On Permit <br /> ,Type Permit/Service Requested:monitOring- well--_L1Stallation--. <br /> Roger F'oott Associates Address H Emergency Telephone No. <br /> z Applicant Name —�-- - CA 9 5 6 91 <br /> u W. Sacramento, business Telephone Na. <br /> 1766 Monte Diablo Ave. Stockton _- A ue —STockt-o� <br /> QProperty Location/Address . ] 2 3 N. <br /> Chapin Broters , Inc. Address - . <br /> J Property Owner Address <br /> LOperator's Name Restaurant, Maximum Seating Capacity <br /> Total Building Sq. Footage ❑ MEAT MARKET <br /> MARKET RETAIL <br /> t. FOOD ESTABLISHMENTSFOOD ❑ 'FOOD MARKET WHOLESALE <br /> ❑ RESTAURANT ❑ ICE PLANT ❑ BAKERY <br /> C3 FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ITINERANT RESTAURANT <br /> IJ LIQUOR STORE C1 BAR ❑ FOOD VENDOR <br /> ❑ ROADSIDE FOOD STAND ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION. <br /> ❑ CONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units — <br /> ❑ MOBILE HOME PARK/No. of Spaces 13CHEMICAL <br /> 3, WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ WATER HAULER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections)MMING POOL ❑ SPA C3 WADING POOL 13 NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH <br /> 5, VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds No of Confining Cages <br /> F '.ENNEL/Runways _-- /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method Animal Waste Disposal Method <br /> Water Supply Source ---- <br /> 6. � CONSULTATION FEE 2 • Uri�t IV <br /> 7. ❑ PLAN CHECKING FEE <br /> R. REAL ESTATE Title Cop <br /> REQUEST. Water Well inspection❑ Sar�e❑ lmany Tela. No.. <br /> Sewage System Inspection <br /> Address <br /> Escrow No. <br /> Seller Address <br /> Seller <br /> �.— <br /> Seller Agent Name <br /> Telephone No. <br /> Service Request For Date <br /> I hereby certify that l 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 /> Title Date <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ PER SITE EACH ❑ January i Received By January 31 ❑ July 1 &RecewendEByl�uly 37 <br /> Fee is Due: C1 ANNUALLY 13 $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> $53 . 00 Review 12/5/90 <br /> FEE �— <br /> LESS 79 . 50 Processg <br /> PRORATION <br /> PLUS <br /> PENALTY $ 31 . 80 Penalt <br /> OTHER <br /> OTHER <br /> Receipt No Permis No <br /> Issuance Date Mailed Delivered <br /> Received by Date 1601 E.NATELTON AYE..P.O.Bos 2009 STOC%7oN.CA 95201 <br />