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r <br /> Applications Will Be P � d When Submitted Properly Completed. Be Si��e ' Sign The Application. <br /> ` t � APPLICATION � r lh � <br /> ' ENVIRONMENTAL HEALTH PERMIT/SERVICES `-�\" '` � �� <br /> ENGINEERS AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND an F000 ESTABLISHMENTS.HOUSING, Make <br /> CONTRACTOR AND OR PUBLIC POOLS. WATER SAMPlINO <br /> BROKER AND OR REAL ESTATE INSPECTIONS LIC NO. <br /> i�ENrSE AND OR POULTRY RANCHES ANO KENNELS <br /> iTRATION MISCELLANEDUS SERVICES ReglSt. NQ -_ <br /> i. .dER �� ����� � -/ COIOr ____. <br /> Application Date Business/Name To Appear On Permit 5 <br /> �Type PermitiService Requested Soi 1 sampling on a second day <br /> `Applicant Name Golden West BUilderS Address 1060 Minnesota Ave.._._P.O. Fox .1236 _- <br /> Brentwood, Ca. 94513 Business Telephone No. 415-930-E666 Emergency Telephone No. _-__—__._ _ <br /> iPropertyLocation/AddressZ577 $. .Patterson. Pass Road- Tracy, Ca. 95376 -__ .__.__ _ ___.______—_.—___ <br /> `Property Owner Arco Fdy 6100 Address .Sdme _______ _-_- _ <br /> (_Operator's Name Sdme _ .. - _-___.._._ _-. _. Address $ame.. __ —__ __ __ ____ <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. 01 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 BATEIING 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 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 __ __ <br /> - _ ------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 - <br /> - _ _. Title -- _ <br /> - ---- -------- ate <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUe: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> �� AT DATE REMITTED AMOUNT <br /> - - - - - 2-1�-�0-- - -- - - --..--- -- <br /> FEE $35.00 . _ Soil. sarnpl 'n�-��sec nd day <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY X3.50 _ _ Penalty _ 1-25-91 X73.50 <br /> OTHER <br /> ()TREK <br /> nernwrrl ny Date :eipt No Permit No Is; :Dale Mailed Delivered <br /> ---- APPLICANT--RETURN ALL COPIES TO� ENVIRONMENTAL HEALTH PERMITISERVICES 1601E HA2ELTON AVE..P.O.Ao■2009 STOCKTON,CA 95201 � - <br />