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Environmental Information Form <br /> Part B <br /> DATE: <br /> (To be Completed By <br /> NOTE: In completing this form, use additional sheets if necessary. <br /> Answer all questions to the best of your ability. If a question <br /> is not applicable to your project, write NA (not applicable ) . <br /> Please do not leave blanks . Incomplete forms cannot be accepted. <br /> PERSON COMPLETING FORM PROPERTY OWNER X AGENT OF OWNER <br /> Name Charles H. Bloom Bloom Co. <br /> AddressFremont St. <br /> City Stockton <br /> State/Zip <br /> Phone949-4121 <br /> A. PROJECT DESCRIPTION <br /> 1. Type of application: Q Use Permit, Q Major Subdivision, <br /> Zone Reclassification, Q Minor Subdivision, E] Site Approval, <br /> Zone variance, Q Other: <br /> 2. Project location: 1990 N. Piccoli Road <br /> Describe the project; i .e. , request being made and nature of use . <br /> Identify specific project components : Project is a tilt-up building <br /> addition to the existing structures - all construction to match existing <br /> 3 . Total acreage of project: 3 # of existing parcels: 1 <br /> Assessor Parcel Us ) :: 101-210-01 <br /> 4 . If there is an existing EIR assessing any aspect of your project <br /> site, provide title and date: No - negative declaration <br /> 5. Other permits and approvals (County, Regional, State and Federal ) <br /> required for this project: <br /> PERMIT AGENCY <br /> Septic relocation --J. County Health District <br /> Building & Grading S. J. County Building Department <br /> Site Approval Application - 5 - (6/86 ) <br />