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Applications Wilt Be",- d When Submitted Properly Completed. Beign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND Ota FOOD ESTABLISHMENTS,HOUSING PAYME'N;.ake <br /> APPLICANTS AND,OR RECEIVE G E*V ECONTRACTOR AND%OR PUBLIC POOLS.NEATER SAMPLING 1 C. C. NO, - -- - - - -- - -- <br /> REAL ESTATE INSPECTIONS <br /> BROKER AND OR POULTRY RANCHES AND KENNELSRe - - <br /> 4rFNSE AND OR MISCELLANEOUS SERVICES NOV 161994gist. NO...._._—. <br /> 3TRATION Color ._ -.----- -. <br /> I. dER <br /> 1 1 -09--90 Business/Name To Appear On Permit Ch �>H��f�Af+i&ALINC • _ <br /> Application Date PERMITISI:RVICES - <br /> �Type Permit/Service Requested: Monitoring Well Installaion <br /> =ApplicantNameRoger- Foott Ass.oha s , Inc ' 916e532542�80arbor- Blvd.-,.-_S.uite-1 �-325-2580 <br /> West Sacramento, CA u ne s Telephone No. . . Emergency Telephone No. — <br /> - <br /> aPrvpertyLoeation/Address 1766 Monte Diablo Avenue , Stockton ,_ Callfornia� _ <br /> - --- - --- <br /> JProperty Owner Chapin Brother 5-,- nC . _ -- _-- Address 1.20 3_- N.._CarIto-n—Avenue_,—Stackto-1--.- <br /> Chapin Brathers , Tnc . _ Address 1203 _N.. .-CarJ_l_onvA_v_E! _ 1szo_ktQn <br /> Operator's Name <br /> 1. FOOD ESTABLISHMENTS Total BudRestaurant, Maximum Seating Capacity <br /> Building 5q. Footage 11 MEAT MARKET <br /> Q RESTAURANT El FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ..__.._..- ..------ <br /> ❑ 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 /> 11 CERTIFICATE OF OCCUPANCY <br /> 11HOTEL/MOTEL/No. of Units ---_--- <br /> © MOBILE HOME PARK/No. of Spaces _—_ <br /> 3. WATER QUALITY El 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 /> .ENNEL/Runways .__. - -_ /Animal Population No. No. of Confining Cages —.. <br /> Sewage Disposal Method -------- <br /> Solid <br /> ----_--Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Dis Method <br /> 6, 19 CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample Title Company <br /> Sewage System Inspection CI Address ---_-- <br /> Tele. Na. <br /> Escrow No. - -- _-- -- -- <br /> Seller _ __ - Seller Address <br /> Telephone NoSeller Agent Name -- <br /> , - - - --- - g - -----— ----Service Request 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 /> TitteSenior-Geologist Date 1 1 -9-90 �— <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT-�❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received EByITJuly 31 <br /> ~ BILLING REMITTANCE r S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE s31� (-eV e',1_ _ ..._._-J__.-._�.� 5 _K- <br /> LESS <br /> PR.ORAT IONr_ S �� <br /> • ----`�4.Std _p <br /> PENALTY - . 6 , -SU t� G f'2 <br /> � _ c� <br /> OTHER _._ -..------ -- - - -- <br /> OTHER --. _ -- - <br /> _ ._. Dair -- - -' --`- Rer_C,pt Nn _ Pruro Nn Issuance Date Mailed De4ive red <br /> R Prewp(1 by L- <br /> -- APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITIS ERVICES <br /> 1601 E.HAZELTDN AVE.,P.O.Box 2009 STOCNTON,CA 45201 <br />