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i p U t ly — - ---J--- j r <br /> ° �Q APPLICATION — BUSINESS LICENSE? <br /> i � SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1 DEG 2 3 2015 <br /> BUSINESS LICENSE NO. �S L <br /> \q_•.- �;.• ENVIRON MENTAL HEALTH <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name: <br /> Business Address: 17300 v Cross St <br /> DBA Mailing Address: �q ryt� City: LI(�P State: (q zlP:y Z�g <br /> Phone#: L U Assessor Parcel Number(s): <br /> Email: <br /> Other Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation:: <br /> Type of Organization: XSingle Owner ❑ Partnership ❑ Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: S' Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: z- Applicant First Name: <br /> Applicant Mailing Address: p O 8 C: , <br /> City L)L �� r� State Applicant-Phone No: 7 C./- 7 2 7- Y(.;'•K M <br /> Water Supply: ,Wublic ❑ On-site Well Sewage Disposal:X Public ❑ Septic System <br /> Wiil there be any sale of firearms? ❑ Yes No <br /> NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> 1,affirm,under penalty of perjury that all the above information is true and correct Date: <br /> I,the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its <br /> agents, officers and employees from any aim, action or proceeding against the County <br /> arising from the Owner/Agent's project <br /> jZ—za- 1 � <br /> Applicant's Signature <br /> STAFF USE ONLY / 1 <br /> G/P Designation: L L Zoning: L - L Use Type: �r � a/ .�c 7 .t - ��� r f <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services Planner Name: - <br /> Building Inspection <br /> Environmental Health Div 5�� �j v u �% �' ILI I� <br /> Fire Warden <br /> Public Works <br /> M.H.C.S.D. _ <br /> License Approved For- <br /> Remarks: <br /> orRemarks: <br /> e L7� r l V l7 -------- Occ.Grp. <br /> Accepted I Complete: Date: <br /> F/AppticationsForms&Handouts/Planning4piications/Business License(Revised 02-2415) <br /> Page 2 of 6 <br />