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R /LU L- 17 - WI(p <br /> a - APPLICATION — BUSINESS LICENSE <br /> FEB U 3 2016 SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Y� <br /> RONMENTAL HEALTH BUSINESS LICENSE NO. 64 L U D 3 3 <br /> ITI SERVICES <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name: m z <br /> Business Address: 3 vN cross st n <br /> DBA Mailing Address: S City: T r C ZIP: q 5 <br /> State: <br /> Phone rF (20-t g SS IQI ii,.0Assessor Parcel mber(s): 5'O <br /> Email: <br /> Other Businesses at this Address: YvL <br /> Previous Business at Address: tJ PC <br /> Description of Business Operation:: AAo <br /> Type of Organization: Single Owner ❑ Partnership ❑ Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: .$- Estimated Number of Part Time or Seasonal Employees: r/ <br /> Applicant Last Name: Z C t O Applicant First Name: ey <br /> Applicant Mailing Address:155' Vj. ^%yer.Ii, rt+ <br /> City T r State CIA ZIPj53!7tpj Applicant Phone No: 20'A LOM— Oer, <br /> Water Supply: 01Public On-site Well Sewage Disposal: ❑ Public Septic System <br /> Will there be any sale of firearms? ❑ Yes No <br /> NOTE: ANY CHANGE OrOCCUPANCY AY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> I,affirm,under penal y of pe ur th all the above information is true and correct Date: <br /> I,the Owner/ ant a ree,to efe d, ndemnify,and hold harmless the County and its <br /> agents,officers and mploye s fro any claim,action or proceeding against the County <br /> arising from the Own r/AgenIJAI 's p . 1 [3 6 �l ct. <br /> to <br /> Applicant's Signature: <br /> STAFF USE ONLY <br /> GIP Designation: = L Zoning: L,, Use Type: 17.To o 1a s f`e✓✓jc C —44L-fa /gyp � g�f <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services ti Planner Name: r 7 2 <br /> Building Inspection <br /> Environmental Health DN 1,^ S w 1W k)7 16-S <br /> Fire Warden T"C <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved For. <br /> rApt.sd <br /> : <br /> Occ.Grp. <br /> as Complete: Date: <br /> F/ApplicafionsFonns&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 2 of 6 <br />