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�a Applications Will Be Processed When Submitted Properly Completed. Be Sure-.To Sign The Application. <br /> APPLICATION ' <br /> EllI IRONMENTAL HEALTH PERMIT/SERVIy <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLfCANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make ;ti <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir.FNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION R.G. 4421 MISCELLANEOUS SERVICES Regist. No. <br /> I. .AER Color <br /> 5/16/88 Applied GeoSystems <br /> (Application Date Business/Marne To A pear On Permit <br /> IwType Permit/Service Re nested: Environmenta invests anon <br /> 4 <br /> ApplicantName <br /> 452-2901 <br /> CaliforniaApplied GeoSystems dr /+19-1--E—Power nn oa , , <br /> 95826 - � <br /> 1Business Telephone No. Emergency Telephone No. <br /> IL Property Location/Address 1665 Pacific Avenue, Stockton, 94596 <br /> a ,Owner UNOCAL Corporation Address 2175 N. California Ave. Wa nut Cree , <br /> '[Operator's Name N/A Address <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 SourceAnimal Waste Disposal Method <br /> Proposed work p an or assessment of soil and groan — a e <br /> 6. ® CONSULTATION FEE <br /> 7. El PLAN CHECKING FEE at former UNOCAL Service StatlOn o. <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection C3 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 rules and regulations 94 the San Joaquin Local Health District. <br /> Project Geologist 5/16/88 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLLIS <br /> PENALTY 12 <br /> OTHER , <br /> OTHER 1,2Y <br /> R ved by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />