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Applications Will Bessed When Submitter '' grly Completed. Bie To Sign The Application. <br /> _ APS TION <br /> ENVIRONMENTAL TH PERMIT/SERVICES <br /> ENGINEER'S AND%OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING - -- --- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .InENSE AND/OR POULTRY RANCHES AND KENNELS ' <br /> 3TRATION MISCELLANE00"WVICES � Reg ist. No. <br /> BER Color .-- -- -- --- - - - - <br /> Application Date grBusine s/ me To A ear O Pe[ It <br /> v,Type Permit/Service u Nce <br /> Underound forage "fank"Irts 'allation Nspectloo - <br /> eyii it — 1390 Will Past RCTATelep <br /> to <br /> a Applicant Name - - _ ____ -_ Address _ <br /> GoncorcT, CA 94 _____ _ Emergency ne No.- usssTelepi ne No.- - 9 Y -- <br /> 72-5—rac vd. , frac , CA <br /> a Property Location/Ad res y- y _ - <br /> aProperty Owner She 1oil- - ---- ----- -- Address <br /> Carl Cox 37�acy v T. <br /> Operator's Name -- __-_- Address _ <br /> 1. FOOD ESTABLISHMENTS T tal Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET R TAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING.PLANT ❑ COMMI ARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR ORE ❑ BAR ❑ ITINERANT RES`TA ANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SAGER ❑ FOOD DEMONSTRATION ❑ FOOD VEND R <br /> ❑ VENDING MACHINES/No. of __ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING EHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees_ _ _ - <br /> ALL APPLICANTS: Total Employees Including Operator_ __-- <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPA CY <br /> ❑ MOBILE HOME PARK/No. of Sp'ESAMPLE <br /> 3. WATER QUALITY ❑ WAT (Bacterial) CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM RFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIM ING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRYRM/Maximum No. of Birds <br /> r ;ENNEL/Runways _.- - _ /Animal opulation No. _ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE Underground Std a e Tank Installation Inspections <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title mpany <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 dolb-_,,n accordance with San Joaquin County <br /> ordinances, state laws. N, <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 1%LLP90 REMITTENCE REMITTED AMOUNT DUE CHECKED <br /> TT�� AMOUNT <br /> FEE $52.50 x 3 hrs. overtime inspection 8/23/90 $157,50 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER $35.00 x hrs. regular i:nsepcti:on 8/20/90 $105.00 <br /> OTHER „!"it $262.50 Total <br /> ' FROtvi BILLING DIED TO PAST DUE ACC-01 pITr' <br /> Received by Date ReceiPfUty.° Permit No. `%' Issuance Date Mailed Delivered <br /> T CKTON CA 95201 <br />