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Applications Will Be Process en Submitted Properly Completed. Be Sure T The Application. <br /> APPL.I9ATION <br /> ENVIRONMENTAL_HEA!TH PERMIT/SERVICES <br /> ENGINEER'S ANDzOR -''�"" IF VEHICLE INVOLVED, GIVE <br /> sAPPLICANT's AND/OR FOOD ESTABLISHMENTS.HOUSING Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING —BROKER-W ID/OR . REAL ESTATE INSPECTIONS Lic. No. __— <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> 1. .AER __ _.._._. _....._ _ . . - "='.„-' Color .— ------- <br /> Application Date_—_— _.__. -._. ___ Busine s/ me To A ear O Permit <br /> oType Permit/Service qu to <br /> UncTergroung me dank `instal l ai;i on Inspecions <br /> z They) it 1390 Wfl ass Rd. , Suite 900 <br /> a Applicant Name ____. —_____ Address <br /> �onCOr�, OA 94"52(� _ <br /> usi(� ss Teleph ne No.— Emergency Telephone No. <br /> a Property location/Addres3�-2J��aCy tS�Vd. , �raC�/, C� <br /> Shea!1-0-i 1 <br /> 'i Property Owner _ —----- Address <br /> Operator's Name - d. <br /> Carl COX Address — �25 aCy V <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 /> a 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 /> r :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 Underground Storage Tank. Installation Inspections <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 /> I 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 1 &Received By July 31 <br /> L G REMITTANCE $ REMIT <br /> BASE EXPLANATION 1% -90 DATE AMOUNT <br /> 1 REMITTED AMOUNT OUE CHECKED <br /> _ <br /> J FEE _ -- $52.50 x hrs. over ime inspection 8/23/190 $157.50 <br /> li LESS —� <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER $35.00 xregullar insepc+n 8/20/90, $105.00 <br /> OTHER ,,A i— --- -- -- ----- $262.50 Total <br /> -,� ._ '"6'r8 ✓.a�.v® ''`1 ,x,0 � _, <br /> �` <br /> Received by Date Receipt No` Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />