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'Applications Will When Submitted Properly Completed. eted. Be Sure To Sign The Application. i\ ENGINEER'S AND/OR APPLICANT'S AND/OR CONTRACTOR AND/OR BROKER AND/OR LICENSE AND/OR REGISTRATION NUMBER SAN JOAQUIN LOCAL HEALTH DISTRICT APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES FOOD ESTABLISHMENTS, HOUSING PUBLIC POOLS, WATER SAMPLING REAL ESTATE INSPECTIONS POULTRY RANCHES AND KENNELS MISCELLANEOUS SERVICES GENERAL IF VEHICLE INVOLVED, GIVE Make Lic. No. —_ Regist. No. Color _ [Application Date 30 Apr 85 Business/Name To Appear On Permit Naval Communication Station Type Permit/Service Requested: Removal �f�,QOQ ��j'�'9� erQTround Waste oil tank �Applicant Name hTaval ('nmmtrnjratinn Ci -,q -i On Address Roug]T & Ready Island, Stockton,__ C3 to 95203--50-0-0-_____ Business Telephone No. X09 944-0244 Emergency Telephone No. (209 944-0235 iProperty Location/Address Rnt,gh & Ready Tsland, Stockton, 9 203-5000 iProperty Owner _ Address _ L Operator's Name Address 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT 0 VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees . ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds ❑ KENNEL/Runways /Animal Population No. Sewage Disposal Method Solid Waste Disposal Method No. of Confining Cages Wa er upply Source__ Animal Waste Disposal Method 6. CONSULTATION FEE r fw�rI BUSINESS LICENSE 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT S. REAL ESTATE REQUEST: Water Well inspection 13 Sample❑ Sewage System Inspection ❑ Escrow No. Seller Telephone No. Service Request For Date Title Company Address _ Seller Address Seiler Agent Name _ Tele. No. I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County ordinances, state laws,�ruld r ations of the San Joaquin al Health District. APPLICANT'S SIGNATURE XY 1 . Commander, CEO, USN Title Public Works Officpe JW FOR DEPART ME US E ONLY Fee Is Due: 11 ANNUALLY ❑PER UNIT PER SITE 13 EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE REMIT CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY / OTHER OTHER i Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered ADDI IPAuT—DFTI IDV M I P.nDICC Tel- CYVIDnu"o—A. ..A. vn , . Y.. NVQ DI QCK OR, CA Enclosure (1)