COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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Applications Will Be Proce9- d When Submitted Properly Completed. Be Sureign The Application. APPLICATION (8 " ENVIRONMENTAL HEALTH PERMIT/SERVICES P'GINEER'S AND OR IF VEHICLE INVOLVED. GIVE AVOLICANT'S AND,OR FOOD ESTABLISHMENTS.HOUSING CON IRACTOR AND.OR PUBLIC POOLS.WATER SAMPLING Make _. ._.. ._ ._ ... BPf'KER AND,OR REAL ESTATE INSPECTIONS Lic. No. .. __...._...__. Ir.FNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No._...._—___.. p ;TRATION MISCELLANEOUS SERVICES g 1. aER - Program G T Color - — ---- - —- - Application Date -10-213-90 Business/Name To Appear On Permit ,,Type Permit/Service Requested: a Applicant Name _S h 21 1 0 i l C o m_p a n y...._. _ P . O.-Box.-A0.2-3 _. . _----.__ ---------___--- _-.-__ ._ Address U _ C 0 n C 0 r d ' CA 94524 Business Telephone No. ._. _____ ___ .._ _ Emergency Telephone No. _ --- - - q Property Location/Address 725_..Tracy_.-.B 1-V d_, _-Tracy_., --C A_ .9 5 3-.7_6--_---_---...—_--__.— --- Property Owner --- -- —------------- ----- Address - -- ----- ------ ---- �Operator's Name ___-. -..____----.--------___-.-- Address ------.---_.__-- t. 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 ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators----- 2. perators-.-__2. HOUSING ❑ HOTEL/MOTEL/No. of Units ____ ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No.of Spaces 3. WATER DUALITY ❑ 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 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds F :ENNEL/Runways ____ _ /Animal Population No. _._____--_. _._-_ No.of Confining Cages_ Sewage Disposal Method - — ------- ------ _ - --- ----- _. .... _ - ---------_ - Solid Waste Disposal Method — Water Supply Source — --___-_ Animal Waste Disposal Method 6. ❑ CONSULTATION FEE S-eP--At.tache.d__—__—__—_--____._-_._____— -----------_-_-- __ 7. ❑ PLAN CHECKING FEE _ 8. REAL ESTATE REQUEST: Water Well Inspection❑ Sample❑ Title Company Sewage System Inspection ❑ Address _-- Tele. No. Escrow No. _-------------_-__—. Seller -----------------_-_-_ Seller Address ----------___--- — Telephone No. _ -__-_-- ----.-_—_-- Seller Agent Name Service Request For Date --------- --- -- - --- -—--- -- ---- ----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. APPLICANT'S SIGNATURE X _ —_ Title_ Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE— ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT FEE _ $262 . 50 Inspect ons 12_7 90 — --- LESS PRORATION PLUS PENALTY -_ P`E--V--/ L-T-IE-J --- - -------- ------- ---- ILC OTHER --- DAYS-FROM-81L- �LIE APPIIE —TO PAST --D FA---E—EO--UNGDAM.— --N--T — _ —$-2 a Z5 OTHER - -- ---- Received by Date cel t No Permit No Issuance Date Mailed Delivered APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -