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`-`'"W APPLICATION — BUSINESS LICENSE <br />�o. r <br />-T 1 Z ZO17 SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />a <br />NVIRONF•AENTAL HEALTH BUSINESS LICENSE NO. <br />w, DrDIAIT/^CD1n'ELI <br />TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br />IN N Business Information <br />Business Name: S <br />Business Address: g30(p S • 13h �W Cross St <br />DBA Mailing Address: C) 1�oit- 2 -2 -`IL(. City: '5> C�0 State:- ZIP: R S L <br />Phone #: q 1(P . y SS. -13 $ Assessor Parcel Number(s): 1q - 1 - 9 L <br />Email: r-pc� 0. �A✓� SCo L'pM� <br />Other Businesses at this Address:Iv <br />Previous Business at Address: r QQ\r--Q_ L --p^ In Le„ <br />Description of Business Operation:: (_y SC a ih-\- ^OZA.c_ <br />Type of Organization: ❑ Single Owner ❑ Partnership Corporation ❑ Other: <br />Estimated Number of Full Time Employees: 457 Estimated Number of Part Time or Seasonal Employees: NlAr <br />Applicant Last Name: Qlack p Applicant First Name: <br />Applicant Mailing Address: Q PSp 2191-6 <br />City I State CA zlpmm <br />Applicant Phone No: �16P • <br />Water Supply: ❑Public P• On-site Well <br />Sewage Disposal: ❑ Public Septic System <br />Will there be any sale of firearms? ❑ Yes No <br />NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br />I, affirm, under penalty of perjury that all the above Information is true and correct <br />I, the Owner/Agent agree, to defend, Indemnify, and hold harmless the County and Its <br />agents, officers and employees from any claim, action or proceeding against the County <br />arising from the Owner/Agent's project. <br />Applicant's Signature: <br />Date: <br />STAFF USE ONLY <br />G/P Designation: Zoning:10 1 Use Type: <br />DEPARTMENT APPROVED DENIED DATE <br />Development Services Planner Name: <br />Building Inspection <br />Environmental Health Div PA- Qv S <br />Fire Warden <br />Public Works <br />M.H.C.S.D. _ <br />License Approved For, Lt; ,-�e-� ZfLt� T,C .� L.IJ/ <br />Yet 'te� �3 �Lc: ►-ri eY ' I <br />Remarks: <br />37 Occ. Grp. <br />Accepted as Complete: Date: <br />F/ApplicationsForms&Handouts/PlanningApplications/Business License (Revised 02-2415) <br />Page 2 of 6 <br />