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Applications Will Beased When Submitted Properly Completed. B <br /> ENGINEER'S AND/OR o Sign The Application. <br /> APPLICATION 1% <br /> IRONMENTAL HEALTH PERMIT/SERVIC IES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make _-..___ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> ------------------ <br /> I .NSE AND/OR POULTRY RANCHES AND KENNELS _ <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I, ,BER ____ . - _ Color <br /> (Application Date_ -_1 '. _-__ _____ Busine s/Name To Appear On Permit &`R. o__ P,oDUGTS <br /> ►u-Type Permit/Service Requested: 1-��•�IuA7 Pl1 p 1w57_kL_LA-j <br /> N - }�E,p <br /> - >AI R- ----- ---. <br /> u Applicant Name - GO �RQ�V_�� �OA ress p Q-. _[3 4X_50-0— <br /> U1 <br /> _50- � <br /> _ -S kt s M A'�p �-_C/ usiness Tele hone No. 5'ZZ`i'•?-`l-7( Emergency Telephone No. <br /> i �..- -- - -- - 9 Y P '� 4 <br /> a,LrC.A4� Opr}� ess <br /> p <br /> L-+'c /Addr ---- --- — <br /> a r P1GQ } Otp_C7L1T�- Q. - Address -I , .t7_._�3t �JAtiI ."ATSO � � <br /> -- -- -- - <br /> Operator's Name . A�C-E7. _p�Q�IILT.S— r' -- - <br /> L- D <br /> <br /> <br /> 3667 <br /> AR ruReP�N�NC+ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> 6. LU CONSULTATION FEE 3 5 C S5y i�Q <br /> 7. Ud PLAN CHECKING FEE 3 0 <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection ❑ Address __ Tele. No. <br /> Escrow No. <br /> Seller -__ _- --_-_._- Seller Address ('* li+= <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 re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ Title! Date <br /> FO 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 /> � REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -- J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />