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Applications Will Be-Orc d When Submitted Properly Completed.Be Sur Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVIC S <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> I, ,BER _ Color <br /> (Application Date Business/Name To Appear On Permit Independent Trucki na <br /> ,AType Permit/Service Requested: <br /> `Applicant Name Gregory J. Basso Address P BOX 6567, S ark on 95 n6 <br /> Business Telephone No. Emergency Telephone No. <br /> a Property Location/Address 401 S I i nrnl n Stockton <br /> `Property 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) PA Yhl <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 11 SPA 11 WADING POOL 11NATURAIR 1 1E <br /> S. VECTOR CONTROL 11 POULTRY FARM/Maximum No. of Birds 11 YY <br /> .ENNEL/Runways /Animal Population No. No. of Confining@;&fs <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method ENWRG�11 <br /> Water Supply Source Animal Waste Disposal Me" TAL <br /> 6. Q CONSULTATION FEE Solid Waste ste Permit ffMFRVICE$ <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample 13 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 la Sand rules and re ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Title v J Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PE IT ❑ P SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOU T <br /> FEE $525.00 ee Attached 9128/89 525.00 <br /> LESS <br /> PRORATION <br /> PLUS LIED TO PAS DUE ACCOL INTS 30 <br /> PENALTY <br /> OTHER <br /> OTHER <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 4009 STOCKTON,CA 9540 <br />