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eco APPLICATION <br /> BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ` APR 2 9 2015 <br /> I BUSINESS LICENSE NO. �L �5 — <br /> VISC <br /> TAL HEALTH <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name: m l_ <br /> , <br /> Business Address: Cross St <br /> DBA Mailing Address: City State: ZIP: <br /> Phone#: Assessor Parcel Number(s): <br /> 5 <br /> Email: <br /> Other Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation:: <br /> )Ili Ahlb <br /> Type of Organization: ❑ Single Owner ❑ Partnership Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: Applicant First Name: -` <br /> I I- <br /> -Applicant Mailing-Address: <br /> City1. Stat& 1 T Applicant-Phone No: L <br /> Water Supply. ❑Public On-site Well Sewage Disposal: ❑ Public Septic System <br /> Will there be any sale of firearms? ❑ Yes 9114o <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 Date: j <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 /> STAFF USE ONLY <br /> GIP Designation: Na Zoning: Use Type: 2�tAi o n - M tivi rA <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services �� Planner Name:'---7y. l <br /> Building Inspection <br /> Environmental Health Div !-rysv $O /S <br /> Fire Warden �.Q <br /> Public Works <br /> M.H.C.S.D. i^ <br /> License Approved For. rl�%�. �•�,� lt%i G�A ` <br /> ii'11A,w( i t i' k Al� u,Qe, n o rn�)yp- i n I � c�c�fit .►^ G wa.�J <br /> Remarks: i✓ - bdI y -o?0W3 ' q- 11 6Lj-?(> /,9ya <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F/ApplicabonsForms&Handouts/PlanningApplicabons/Business License(Revised 02-24-15) <br /> Page 2 of 6 <br />