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Applications Will Be Procr ;ed When Submitted Properly Completed. Be Surr To 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 /> it ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEOUS SERVICES <br /> Color <br /> I. .SER <br /> (Application Date 13 Sept. 1988 Business/Na a To Appear On PermiVorth Cal Construction <br /> w Type Permit/Service Requested: r i art t 11P[`I< -� �Yc T- C('P N I,/D <br /> i Applicant Name North Cal Construction Address P. 0, Box 588,_ Stockton, CA, 95201 <br /> Y Business Telephone No. 465-5886 Emergency Telephone No. <br /> i Property Location/Address DeRollo Mazda, E Miner & N Grant Stockton CA 5!0-3: N• <br /> -i Property Owner <br /> De Rollo Nazda Address P 0 Box 100308 '-Stockton, CA. 9521 <br /> 4Address <br /> [Operator's Name <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. 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 /> r !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. Q CONSULTATION FEE Consultation, ° F diner & N Grant <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r es and regulatio sof the San Joaquin Local Health District. <br /> 9, EstintEl 10 Aug. 1988 <br /> APPLICANT'S SIGNATURE X � �G�F�/�r�� 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ! c ed by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz Has STOCKTON,CA 5520 <br />