COMPLIANCE INFO_1974-1992 - Laserfiche WebLink

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Applications Will Be Ned When Submitted Properly Completed. BeS o Sign The Application. tv APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make - CONTRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING Ma — - -- BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. .i. ENSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION Unit II MISCELLANEOUS SERVICES Regist. No. It ..3ER ._ -- Color -- — -- - - 'Application Date ____—Business/Name To Appear On Permit _—. Forward Inc. _ Landfill Type Permit/Service Requested uApplicant Name _____'E}�A�' T .._ter_,, _ Address _._____ _ 4 -------------- .. Business Telephone No. Emergency Telephone No. `Property Location/Address `Property Owner—forward Inc, - __ _ Address -F . Box 136 Stockton CA 9591016 --- Operator's 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 ❑ 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 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — r :ENNEL/Runways _ /Animal Population No. No. of Confining Cages Sewage Disposal Method Solid Waste Disposal Method _ Water Supply Source _ _ _ Animal Waste Disposal MethodJA 6. CONSULTATION FEE Solid Waste - Soils Reidew - Overtime � 7. ❑ PLAN CHECKING FEE p -R '1;jUR UI 8. REAL ESTATE IVV�RONMEIVT TH RVIC -- AL HEALS REQUEST: Water Well Inspection❑ Sample❑ Title Company fCr_— Sewage System Inspection ❑ Address _ _ Tele. No. Escrow No. ---. Seller ___ Seller Address _ Telephone No. _ Seller Agent Name _ Service Request For Date I hereby certify that 1 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 ❑ PFR SITE 11 Fnrw 11 1.--, 1 a 0 --- ;.,., ..,.,....... o, 11 .. ... BILLING REMITTANCE $ Received by Date Receipt 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 BASE EXPLANATION REMIT CHECKED DATE DATE REMITTED -p AMOUNT FEE 3107,�� see attach 12/28/9 &NT LESS � PRORATION PLUS PENALTY OTHER PES _ �D r PA OTHER DAYTO S FRO BILLING D TIE. Received by Date Receipt 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