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Applications Will Be Processed hen Submitted Properly Completed. Be Sure To S n The Application. <br /> • 40 APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> E d,INEf-R S AND OR IF VEHICLE INVOLVED, GIVE <br /> A:PLICANT$AND%OR f000 ESTABLISHMENTS.HOUSING Make ' <br /> C�NrRACTOR AND,OR PUBLIC POOLS.WATER SAMPLING <br /> BFt^KER AND'OR REAL ESTATE INSPECTIONS Lic. No <br /> 14ENSE ANDiOR POULTRY RANCHES AND KENNELS Regist. No <br /> 'fRATION Pro ram U G S T MISCELLANEOUS SERVICES - <br /> 1. BER Color <br /> iApplication Date - 10-23-90 Business/Name To Appear On Permit <br /> c,Type Permit/Service Requested: _ <br /> <Applicant Name She11 Oil _Company _ _ _ Address P . O. Box 4023 <br /> - ---- <br /> C o n c o r d , C A 94524 Business Telephone No.___ Emergency Telephone No. <br /> a Property Location/Address 3 7 2 5_ _T r_d cy_B 1 v d_ ,__.Tracy,- C A_ 9 5 3 Z fi- <br /> - --- -- <br /> 4Property Owner __ - _ Address -_ _ _ -_ __---_- --.-- -____-- <br /> Operator's Name ____.___ ___._---__ _._____ ----- - 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 /> F '.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. ❑ CONSULTATION FEE . ._.--_S_eE A_t t 1 Ch.e d------ <br /> 7. <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 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 /> 1 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. <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 I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE $262 . 50 Inspections 12-7 90 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PERlAL.TIFS ILC�E APPI.IE TO P,�S <br /> —---- <br /> OTHER DAYS.FROM-81LUNG UA E. -_.._ TD F AGE®UNT W-1 <br /> __------ - -._$..2.8.2_..-5�- <br /> OTHER <br /> Re(-PivP,d by Date _ceipt No Permit No IsCate Mailed Delivered <br /> -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 --- <br />