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Applications Will Be Pro- ed When Submitted Property Completed. Be Sur" -o Sign The Application. <br /> %W"P+, APPLICATION • <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIS <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S ANDfOR FOOD ESTABLISHMENTS.HOUSINGMake <br /> APPLICANT'S ANDiOR <br /> CONTRACTOR ANDIOR PUBLIC POOLS,WATER SAMPLING _ <br /> REAL ESTATE INSPECTIONS Lic. No _ <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS _ <br /> Regisl. No.. - <br /> ,rFNSE ANDiOR MISCELLANEOUS SERVICES Color <br /> iTRATION ---- -I. 3ER <br /> Application Date May 24, 1989 Jim Thome Oil <br /> Business/Name To Appear On Permit <br /> ,Type Permit/Service Requested: water. Quality <br /> z.ApplicantName Staal, Gardner & Dunne, Inc. _ Address 121 NorthFir St., SuiteF Ventura Ca.93001 <br /> Business Telephone No. $_05)6_53-5556__ Emergency Telephone No(805)653-5556 <br /> Property Location/Address 2402 North Pacific Avenue- <br /> 0- <br /> Properly Owner California Fuels Address P.O. Box 1207 Stocktoz�Ca. 95201 <br /> California Fuels _ Address P•0. Box. 1207 StockMg Ca._ 95201 <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 /> - <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 OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL Conduct Soil Vapor Survey to <br /> ❑ PUBLIC WATER SYSTEM M SURFACE WATER SUPPLY ❑ WATER HAULER evaluate for soil contamination. <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 /> .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. a CONSULTATION FEE ��5 C.,_ - <br /> 7. ❑ PLAN CHECKING FEE — -- - - <br /> a. REAL ESTATE <br /> REQUEST: Water Well Inspection 11 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 /> ordinance$, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> Staa2 Gardner & D e Inc. yzlF <br /> APPLICANT'S SIGNATURE ' Title R���kq�47LIJI�-Date aeg <br /> FOR DEJARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8&Received By January 31 <br /> C1 July 1 8 Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> — _ — DATE _ DATE REMiTTED AMOUNT DUE CHECKED- <br /> - --- — .-- — — - - - -- --F — AMOUNT <br /> FEE � <br /> LESS <br /> PRORATION5U — <br /> PLUS <br /> PENALTY_ <br /> OTHER <br /> - <br /> OTHER <br /> Received byOate Receipt No Permit No _ Issuance Date Mailed Delivered <br /> APPLICANT— TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />