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Applications Will Be Pr ssed When Submitted Properly Completed. Be To Sign The Application. APPLICATION ' ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEERS AND:OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND/OR FOOD ESTABLISHMENTS. HOUSING Make CONTRACTOR AND -OR PUBLIC POOLS. WATER SAMPLING BROKER AND OR REAL ESTATE INSPECTIONS Lic No. DENSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Reg ist. No.. I. BER Unit II Color Application Date _ Business/Name To Appear On Permit North County Landfill o Type Permit/Service Requested: -__ _ _ _ _. _ _. _ _ _ - -__- jAPPlicantName NOrth_COLTnty Landfill/S.J. CO. Address P-0—Box-1810. Stockton, CA _.95201_ - _ Public _ Works _. P - -. - - --- Emergency P - _ Business Telephone No. Emer enc Telephone No. aProperty Location/Address North County_Landfill a Property owner _Sc371._JOa�n�in-_County _______ __ Address _ P,O, BQx_1810,_Stockbm,L. CA 95201 _ 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 Disfosal Method 6. LR CONSULTATION FEE ---SO kid__WaBte---= r. -P-OZIlllt—__Overtlnit? ,, -- --- ---- - -_------ 7. ❑ PLAN CHECKING FEE -- - `k - - a. REAL ESTATE REQUEST: Water Well Inspection[] Sample❑ Title Company Sewage System Inspection ❑ Address -__-____--"L, , _.._-Tele. No. Escrow No. Seller --_-_- _ ___ ._ __. ___ ___ Seller Address _-__-- _ --_--- -_ ` -- —-----------_-_- . Telephone No. __ ____ ___.__..______. Seller Agent Name Service Request For Date 1 hereby certify that I 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 ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 FEE LESS PRORATION PLUS PENALTY OTHER OTHER _— --- BASE EXPLANATION -------- BILLING DATE - REMITTANCE DATE — $ REMITTED AMOUNT DUE REMIT CHECKED AMOUNT $2_,88a,54- -see_attac ed_AV28J 0_ ___-- $2,885.50 n r + TT) fr� -1E ACCoUN S 0 Received by Date Receipt No Permit No Issurnce Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE.. P.O. Bos 2009 STOCKTON, CA 95201