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Appl.cabens 'trill Re ocr•see Submdled Properly Compleled Be Sure To Sign The Application. <br /> APPLICATION <br /> EN ONMENTAL HEALTH PERMIT/SERVIC <br /> IP <br /> ENGINEER'S AND!OF IF VEHICLE INVOLVED, GIVE <br /> A r'�L[CANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND•OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> STRATION MISCELLANEDUS SERVICES <br /> I. .BER Cs -/ CO101 <br /> [Application Date Business/Name To Appear On Permit���% <br /> wType Permit/Service R�egnugsted: ..��c^ "7� <br /> i Applicant Name /d/� �"�a`�� Addre <br /> r <br /> Business Telep ne No. Emergency Telephone No. <br /> iProperty Location/Address <br /> Property Owner cs CJL-J Address <br /> a _?j__�,qa r.S Address <br /> Operator's Name (( - - <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Awau^^ ^- <br /> ❑ RESTAURANT ❑ FOOD MA avCT-`- " - ' <br /> 9090-_103 <br /> apNK OFSTOCKTON 1211 <br /> - cowrawnws.a'uF owx~A aT RANT <br /> mac:-INSI co,� <br /> 22542 <br /> uurORNIA C wy oH,cAla lag i'1,aw <br /> 99►6tb H.uru w+ KTu 9sterF- <br /> P,p aye all STOCKTW, <br /> PNoriz am/w-wn Ei I <br /> a� DOLLARS <br /> PAY DATE CHECK NO. c P5 Ic21 <br /> e 1s <br /> TO THE <br /> - STOCKTON SERVICE STATION EQUIP.CO.,INC. <br /> ORDER Or <br /> i <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> I <br /> Service Request For Date <br /> I hereby certify that I have prepared t tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s,and ules re ulat he df the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Title rAb� ANI� Si Date -IA —5ff— <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANN ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -- <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIVBERVICE9 1601 E.NAZELTON AVE-P.O.Box 1009 STOCKTON.CA 95101 <br />