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k Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' <br /> 'ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> I <br /> APPLICANT'S AND/OR <br /> CONTRACTOR ANDlOR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> "'F_NSE AND/OR REAL ESTATE INSPECTIONS --- <br /> r iTRATION POULTRY RANCHES AND KENNELS LiC- NO. <br /> I. BER MISCELLANEOUS SERVICES Regist. No. �~ <br /> / Color <br /> ' Application Date / <br /> q Business/Name A pear On Permit <br /> . ,Type Permit/service Re uested:.___.�_ _-`���� <br /> 6 Applicant Name _ <br /> u �-��_-��f Address __-- <br /> i Business Telephone No. -4- __-_6 �T� ��- <br /> <Property Location/Address . y € G l- Emergency Telephone No. <br /> Property Owner_.__�,_� �✓Ga. <br /> _-- AddressFr� / i -- <br /> if„e CMeCK.8 OELIV eREG WOR PAV MENT - ` <br /> oN TMC FOLLOWING ACCOUNTS, �— — <br /> ----- <br /> ,- <br /> RICH MART <br /> JIRD THORPE, DISTRIBUTOR .OF QUALITY PRODUCTS <br /> 10448 <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> - ----- <br /> LODI. CA 95241-0357 <br /> 90-10311211 <br /> PAY <br /> TOTAr TO THE: <br /> ORDER OF <br /> 019COUNT -- —�` $ <br /> AMDUNT of CHCCH J <br /> --DO LABS f <br /> LObr OfrICE <br /> 120 W.Walnut 5L,Lodi,CA 45210 <br /> I <br /> "'01041,8111 01 <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> Animal Waste Disposal Method <br /> 8. CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE ` e, <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Com an <br /> Sewage System Inspection ❑ p y <br /> Address __ <br /> Escrow No. -�—�_ - --- Tele. No._ <br /> Seller _ Seller Address <br /> Telephone No. � ---- <br /> 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 --� <br /> ordinances, state laws,and rules and regulatio of the San uin Local Health District. q County <br /> APPLICANT'S SIGNATURE <br /> Title_ <br /> Date <br /> FOR DEPART',IVIENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PERU IT ❑ PER SITE �� <br /> ❑ EACH ❑ January 1 &Received 8 Januar 33 I <br /> Y Y ❑ July 1 &Received By July,31 <br /> BASE EXPLANATION BILLiN REMITTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ` "'—` -- AMOUNT <br /> LESS `5 rn_-=' - - --- 4(.35 _— <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER !?/"�: <br /> OTHER <br /> iecew ____ _ <br /> eA 6 Date Receipt No -------- <br /> Permit No. Issuance Date <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .�... ..-__.___- Mailed Delivered <br />