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Applications Will Be Psed When Submitted Property Completed. Be To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/09 PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. 8ER 'Color <br /> (Application Date Business/Name To Appear On Permit <br /> oType Permit/Service Requested:--- _ t <br /> 4Applicant Name�1, � (�LCt�{cz?4Y1Cu - SL_N�0 Address liQL] LAC) _ V E' P 6� L�t2r <br /> a - Business Telephone No. __ _ Emergency Telephone No��<_\___Sc-% - <br /> a Property Location/Address ��C�r! _ <br /> aProperty Owner Address _- <br /> DATE gMoukT 71-24 0D & D MANAGEMENT'CONSULTANTS1z106440 HESKET COURT (t <br /> SAN J050 <br /> E,CA 95123 <br /> PAY <br /> DOLLARS <br /> DA <br /> TO THE ORDER OP DESCRIPTION <br /> NT <br /> 1. <br /> f— <br /> NET MIL <br /> � <br /> 994K ✓� SANTA TEREAA-BERNAL <br /> SAN JOSE,Ca 95119 <br /> . wuorun4 wcWrpx <br /> lla il' 11,10DOODO ?000111 <br /> 6. E <br /> 7. ❑ PLAN CHECKING FEE t`� c <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sampler] Title Company <br /> Sewage System Inspection ❑ Address __. Tele. Na. <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 Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE V�� <br /> uD <br /> LESS <br /> PRORATION <br /> PLUS w <br /> PENALTY r� <br /> OTHER <br /> OTHER <br /> ` <br /> Received b7 r Date Receipt No. Permit No. Issua a Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201---- <br />