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xxx , <br />Applications Will Bussed When Submitted Properly Completed. Be � To Sign The Application. "l <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEERS AND ORIF <br />VEHICLE INVOLVED, GIVE <br />ESTABLISHMENTS, HOUSING Make <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />PLIC POOLS. WATER SAMPLING <br />UB <br />PUB <br />REAL ESTATE INSPECTIONS Lic. No. <br />BROKER AND'OR <br />IrENSE AND'OR <br />POULTRY RANCHES AND KENNELS Regist- No. - — <br />3TRATION <br />MISCELLANEOUS SERVICiS <br />Color -- - <br />I. AER <br />'-� <br />Application Date _ > 1� _—� ? - Business/Name To Appear on Permit rt <br />F= <br />rnTYPe Perm ill rvice Requested: <br />��'!' -! zi! a -'. _�c1 ►ter ''r�` , <br />i< 1 1 Lr l r 7 r Address <br />Applicant Name <br />Business Telephone No..—_ i Emergency Telephone No. <br />IL Property Location/Address <br />r1_t _h l- ..— <br />J <br />4 Property Owner. <br />�. rr •: f�, 1 �` - Address _ �" rtrI I! ', - 7'1' or,,, f ]� <br />-_ 1 '`A <br />HERBST ENGINEERING, INC. <br />422-2629 OR 422-2628 <br />5980 - 24TH STREET <br />SACRAMENTO, CA 95822 <br />March 2.6, 19-90 <br />11-111210 <br />PAY <br />TO THE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT.***********r $°131.25/100 <br />ONE HUNDRED THIRTY-ONE DOLLARS AND TWENTY-FIVE CENTS.*-**.***-******_**** DOLLARS <br />BANKNE THE BANK OF CALIFORNIA <br />Sacramento Regional Office <br />770 L Street. Suite 1400 <br />y� <br />Sacramento, Call 95814 <br />FOR 1� E E N O q d <br />7 Q T l <br />ce-, - - - - U <br />Sewage Disposal Metric)() ---- — - -- -- - <br />Solid Waste Disposal Method - -- - -- - — �- - - - - <br />Water Supply Source <br />6. ID CONSULTATION FEE l Animal Waste Disposal Method-- <br />rf. <br />2 �•=�=--�� —'V �J <br />7. I3 PLAN CHECKING FEE -- - <br />8. REAL ESTATE <br />REQUEST Water Well Inspection 11 Sample Title Company <br />Sewage System inspection Address —__ - - Tele No. <br />Escrow No. -- ---- <br />Seller _ Seller Address -- <br />Telephone No Seller Agent Name --- <br />Service Request For Date— <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X _- _ _ -_ — Title <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By Janu <br />BASE EXPLANATION BILLING TREMMTTANCE S <br />DATE DATE REMITTED <br />FEE j r�, f j ? ff r: }fnf t 3,12112( <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Date —.- -- --- <br />31 ❑ .July 1 & Received By July 31 <br />REMtT <br />AMOUNT DUE CHECKED <br />AMOUNT <br />Received by Data ReceiPl No Permit No f Issuance Date Mailed Delivered <br />- APPLICANT ---RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Bap 2009 STOCKTON, CA 95201-- - <br />