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ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,CFYE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.MOUSING Make ---------- <br /> APPLICANT'S ANO/OR <br /> CONTRACTOR ANDIOR PUBLIC POOLS. P SAMPLING Lic. No. ----- -- <br /> REAL ESTATE INSPECTIONS - -"- --" _ <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS <br /> irFNSE ANDIOR ReglSt. NO._---— <br /> 3TRATION MISCELLANEOUS SERVICES Color. <br /> dER <br /> 2f� __ B mess/N a To A pear On Permit �7 <br /> Application Date jo/z �� ,�f^- _ 4 _ -- <br /> TIt- ypePermit/Servic RRegLueLstetl:T, �L - _ Address d --�v� <br /> i Applicant Name -.-E 6G-N.�-- -F-Ll-F�->�%L��— - ---- " <br /> Emergency Telephone No — - - --- <br /> _ Business Telephone No�- <br /> J L- _ <br /> i Property Location/Address . -- --- <br /> ,Property Owner___--_—.___— —._____—".__" <br /> Address — - - <br /> LOPerator's Name .-------------- ------ Address ----- - -- <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage <br /> Restaurant.Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET — <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ 1.lot ir)p CT-OC - <br /> - UNION BANK <br /> ' Slooldon ORxe - -- <br /> 2321 IN March Lane 1210 <br /> . . W ,CA 95207 <br /> ELTA P.C. BOER161 : S *101% <br /> ICK <br /> STOCKTKTON.CA95208 (209)466-4. <br /> ALE6 <br /> INC JY <br /> n Yn}1PY 77 _19 S <br /> +Oil ,ItU, I.,}I � :**35.00 <br /> CHECK NO <br /> N NEGOTIABLE <br /> THE <br /> AFTER 90 DAYS <br /> PAY <br /> TO THE <br /> ORDER <br /> OF <br /> San Joaquin Local Health DiSM.St <br /> II' <br /> a li■0038958■ - E: L2i0009761: 65240.N 2122 <br /> - I ele. No. <br /> Seller -- --- Seller Address _ --- <br /> Seller Agent Name _. .__---.- -- ------ <br /> Telephone No.____. _ ----"- <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 _— ----—���- -" <br /> _ Title— Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH-- ❑ January I A Received By January 31 ❑ July 1 A Recery REBlAI July 31 <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT— <br /> ._____ �6� - <br /> N <br /> ill rS i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER _ <br /> OTHER <br /> Reived by Dale ece <br /> Ript No Permit No <br /> eclaauence Dele Mailed Delimred <br /> . .0 ncou11,11EBVICE3 1601 E.HAyELTON AVE.,P.O.Boa 2009 STOCKTON,GA Kldl­ <br />