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Applications WIII Be Processed When Submitted Properly Completed. Be Sure 10 Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR APPLICATION IF VEHICLE INVOLVED, GIVE CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make --- -- <br /> BROKER AND/OR Lic. NO. <br /> LICENSE AND/OR FOOD ESTABLISHMENTS,HOUSING Regist. No. — <br /> REGISTRATION PUBLIC POOLS,WATER SAMPLING g <br /> NUMBER _ REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> �0 1984 MISCELLANEOUS SERVICES <br /> f Application Date r Business/Name To Appear On Permit _ l`EXACO US U , -IM _ <br /> »Type Permit/Service Requested <br /> Z4ApplicantName ;A, INC Address 1.00 CUT'.I'ING FT("79PrTD, C'A 94004 <br /> `-' -761 <br /> Business Telephone No. 7 <br /> _ Emergency Telephone No. <br /> Property Location/Address 140 WEST C'f .T-=R WAY, STOCKit)N,CA 952.06 _ <br /> iProperty Owner USA _. Address _ SAME AS <br /> L Operator's Name rnA{'n, TTSn _ Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ r--Onr? MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT v 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 ❑ VFNpING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEUNo. 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEURunways /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 ��' '-� �'t ❑ <br /> BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE")-",aNa .a a ❑ DANCE PERMIT <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample[] Title Company <br /> Sewage System Inspection ❑ Address_ 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 1 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 /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE' $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEES <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Z. <br /> a <br /> OTHER <br /> i <br /> o <br /> 0 <br /> 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered = <br /> APPLICANT—RETURkALLCORIIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:200 STOCKTON,CA 95201 W <br />