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783 <br /> Applications Will Be Pr ed When Submitted Properly Completed. Be S o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'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 /> Jr.ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, .BER Color <br /> f Application Date u Business/Name To Appear On Permit <br /> wType Permit/Servipe <br /> AppliC nt Na y �✓ Address <br /> U <br /> us As Ihon No. -3 EmergAcy Telephone No. <br /> ;Property Location/Addre"ss aZ ` <br /> Property Owner Addr ss <br /> .[Operator'sName Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT 11 BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 0 ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE FOOD S6LVAGERJ ��■^"��T�•T�^•' —,��^ �''---_- —= T— <br /> N`I{ E D E BIL WELLS FARGO BANK 95612 <br /> K L E R WALNUT CREEK OFFICE <br /> 2121 N.CALIFORNIA tiL1/D.•STE,670 WALNUT CREEK. CA 84598 <br /> WALNUT CREEK.CALIFORNIA 94590 11-24-1210 - 585 <br /> PH.415-934.0280 <br /> a <br /> TWO H <br /> iFar <br /> PAY Ear Ifata� i�,� �s# �rkLINI?FiEDL��E. Ii Y l�C]LLF�Cy AND �;�:� CEN l ' <br /> DATE A ..�.1 <br /> TO THE 8/02/69 <br /> t3RDER OF ;. t <br /> >='ub1 .l C I-1ca1 th aer v PL <br /> Envi.r' flrtlEr��i�t iI Hezil th <br /> n'09sr. L2u'*E: 12L000248�:�+ 585 <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 K + Title Date ! `U <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE d ` � AMOUNT— <br /> FEE 4' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec ved y Dale Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIC€S 1601 E.HAZELTON AVE.,P.O.Box 2002 STOCKTON,CA 29201 <br />