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Applications Will Bei ed When Submitted Property Completed.Be S Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES: <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/ORFOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/014F111020M PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/ORn gt REAL ESTATE`INSPECTIONS Lic. No. <br /> SENSE AND/OR " 167 l POULTRY RANCHES AND KENNELS <br /> Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> 1, .r3ERColor <br /> P Jur l 1( <br /> - <br /> Application ��x.'y`�_if • Business/Name To Appear On Permit East Stockton Transfer/Recycle <br /> _— <br /> oType Permit/ ervice Requested- <br /> .z Applicant Name East St®'_ktQn Transfer/Recysl e Address 2435 E. Weber. Stockton 95205 <br /> J Business Telephone No. Emergency Telephone No. <br /> Q. <br /> Property Location/Address 2435_E__-1.ehtor A /Q ' Stkn <br /> eProperty Owner Address <br /> LOperator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT 11 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT 11 COMMISSARY ® ICE PLANT ❑ BAKERY <br /> 11 ROADSIDE FOOD STAND 11 LIQUOR STORE 11 BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE 13_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 /> -11 MOBILE HOME PARK/No.of Spaces <br /> 3. WATER>OUALITY 0 WATER SAMPLE (Bacterial) 0 CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑'SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 0 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 /> 4. 93 CONSULTATION FEE Solid Waste <br /> T. 13 PLAN CHECKING EE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 SampleO 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, and rule eQ da ions of the San Joaquin Local Health District. <br /> a <br /> APPLICANT'S SIGNATOR X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1&Received By January 31 ❑ July 1 S Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 472.50 See Attach d 3/5/90 $472.50 <br /> LESS <br /> PRORATION <br /> PLUS PENALTIES ILL P n <br /> PENALTY PA!Z"DUE ACC-01 mr-rc—in <br /> OTHER DAYS FROM BILLING ATE® <br /> OTHER <br /> �(� t. <br /> Received by hDate t 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 />