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Applications WIII ocessed When Submitted Properly Completed Ire To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND.OR PAYMEN VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND%OR FOOD ESTABLISHMENTS.HOUSING ake <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING RECEIVE <br /> BROKER AND,OR REAL ESTATE INSPECTIONS iC. No. <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS c Regist. No. _ <br /> 3TRATION MISCELLANEOUS SERVICES NOV 16 1( 90 <br /> I. BER JJ --- <br /> f Application Date 11 -09-90 Business/Name To A ChXVYIRA&MEALT14C <br /> Appear On Permit PE�Ir/ _ <br /> Type Permit/Service Requested: Monitoring Well Installaion ERVICfS <br /> `Applicant Name Roger_ FOott Asso • a�e_s , Inc. Address 1450 Harbor__-Blvd._,.-B_uit-e_�—____—___ <br /> n West Sacramento, CA p 916-325-2580_ Emergency Telephone No. <br /> - _ _ . _. u nes Telephone No. . . 916-325-258( <br /> 1766 Monte Diablo Avenue — <br /> IL Property Location/Address - _ _ _ .__ _ ,- Stockton, California <br /> /Property Owner -Chapin Brothers Inc. Address 1203 --N.__Carlton__-Avenin_,—Stockton___- <br /> � <br /> Operator's Name Chapin Brothers Inc. - Address 1203 _N. Carlton_lvenu_Pr-__9_tQc_k_t9n_ <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 STOAE ❑ 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ___ <br /> r :ENNEL/Runways -_- . _ _ __ /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method -_-- ...._..--__--__ <br /> -- -------------- <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 Sampled 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. <br /> APPLICANT'S SIGNATURE -( - - - -- - TitleSerilOr Geologist Date 11 -9-90 <br /> FOR DEPARTMENT USE ONLY <br /> Pee IS Due: ❑ ANNUALLY_—❑ PER UNIT ❑ PER SITE — ❑ EACH —❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE ; REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - - - - - - -- - ---- AMOUNT <br /> FEF <br /> --------- ------ <br /> LESS ---- -- ------- — — —PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - - - --------- ---- ----- <br /> OTHER ------- _. - ._ - - --- - - - -- <br /> Rer.��,j by Dale Receipt No Pernvl No Issuance Date Mailed Delivered <br /> '— <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />