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191-11 M g-dW15 <br /> oPa�t"'� APPLICATION - BUSINESS LICENSE <br /> y.•:. <br /> 2:.4 SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> AUG 13 2015 <br /> BUSINESS LICENSE NO. <br /> a�`POMRONMENTALHEALTH <br /> PESMITISEENICES <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name: a . (,rCG !U ' <br /> U' ` <br /> Business Address: Q Cross St ,�/��, <br /> DBA Mailing Address: 5.4N F City: MWOP State: C4ZIP: IJ-Bo <br /> Phone#E: 2 j —02-03 Assessor Parcel Number(s): <br /> Email: G � � <br /> Other Businesses at his Address: NONE" <br /> Previous Business at Address: .'!! <br /> Description of Business Operation:: ' P ND <br /> Type of Organization: ❑ Single Owner ❑ Partnership Corporation ❑ Other: <br /> Estimated Number of Full Time Employees: ZD Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: C ze- I Applicant First Name: (2A4 <br /> Applicant Mailing Address: /Oft M D2 a /CU /J <br /> City ItWMPState CAZIP Cl -0 Applicant Phone No: 30coo—C)576 <br /> Water Supply: ❑Public On-site Well Sewage Disposal: ❑ Public Septic System <br /> Will there be any sale of firearms? ❑ Yes Id No <br /> NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> f,affirm,under penalty of perjury that all the above information is true and correct Date: IP6 <br /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its <br /> agents,officers and employees from any claim,action or proceeding against the County <br /> arising from the Owner/A s proJectrzIX15��Gll Applicant's Signature: � <br /> STAFF USE ONLY <br /> GIP Designation: 1✓ Zoning: Use TypeT'q-4'ck-- 1yf <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services Planner Name: n0 , AUL Sj LI-� <br /> Building Inspection t <br /> Environmental Health Div ' LuOQ/ds9 <br /> Fire Warden [I)orf <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved For: <br /> Remarks: A.c, �," Ccsn 13C L'c��C'( `1 eL%.i )iv Yc� {�V. t ?( `1-7" Dc�Z"/ l <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F/ApplicationsForms&Handouls/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 2 of 6 <br />