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Applications Will Be Procr d When Submitted Properly Completed. Be Sure' Sign The Application. <br /> : . APPLICATION <br /> ' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR /.. F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> lrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Color <br /> I, AER <br /> [Application Date_ 726/88 Business/Name To Appear On Permit <br /> pType PermittService Requested: <br /> z.Applicant Name_Applied GeoSystems Address 4191—P Pocaer Inn Road, Sa am n o, <br /> Y California. 95826 Business Telephone No. (916)452-2901 Emergency Telephone No. <br /> `Property Location/A. ress Beniamin Holt Drive Stockton, CA - <br /> dPropertyOwner_Shell Oil Company Address P 0 Box 4023, Concord, CA 94524 <br /> -LOperator's Name Same as above. 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: -TotalEmPloyees 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 /> F MNNEL/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 Preliminary environmental assessment; ch 1t Sermice Stat'on AGS .1oh No 0120 <br /> -11 <br /> 7. ❑ PLAN CHECKING FEE y <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection fI Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele: No. <br /> Escrow No. ' <br /> Seller v 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, an ules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X /V'-��� Title Project Geologist Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a-Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE ..._ EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATEREMITTED AMOUNT <br /> FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER G v <br /> Received by Da ceipt No. Permit No. 1, „a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO�ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H ELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />