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Applications Will Be t ssed When Submitted Properly Completed. BeTo Sign The Application. t. <br /> �• APPLICATION 1 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR • v�• FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING -- -- - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> i, .8ER Color <br /> Application Date __ Business/Name To Appear On Permit <br /> taType Permit/Service <br /> `Applicant Name ___forward Inc. Transfer Station Address P. 0. Box 6336, Stkn 95206 <br /> Business Tele p hone No.___ _____ __ _ Emergency Telephone No. <br /> aProperty Location/Address Austin Rd. , Stockton <br /> _ _ <br /> aProperty 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 /> 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 Solid Waste <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 Title Company _ <br /> Sewage System Inspection ❑ Address — ______ Tele. No. <br /> Escrow No. — <br /> Seller Seiler Address <br /> Telephone No. _ Seller Agent Name <br /> Service Request For Date -- -- —_ <br /> I hereby certify that I have prepared this applicati' and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I <br /> `' Q <br /> APPLICANT'S SIGNATURE X Title __ ` DateW—k Lif <br /> RTMENT 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMO DUE CHECKED <br /> DATE DATE REMITTED---� AMOUNT <br /> FEE _ $735.00 see attachEd 8/24/90 $735.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -.°10 Lis3 <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 />