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Applications Will Be P&aed When Submitted Properly Completed. Be *To Sign T_he Application. <br /> _ APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANOroR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make - <br /> CONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. ----- --___ <br /> JrENSE ANO/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> 1. AER Color <br /> f Application Data —_.. Business/Name To Appear On Permit - - <br /> IMTypePermit/Service Requested: — .-----------------------�—.----`- -- `l - <br /> s Applicant Name `A..]__ Address_ \: E-LSZ—, �-- <br /> ' Business Telephone No.— _-- _— .___- Emergency Telephone N04:%�%s - <br /> iProperly Location/Address ---_—_-- <br /> A"Properly Owner _ - _ - -__.. Address <br /> L 'y�� n'i?rffil <br /> }I+ L DATE 'INVOICE AMOUNT 11-24/161-- . 1210 <br /> MANAGEMENT•CONSULTANTS <br /> # t 6440 HESKET COURT • �.�O (� <br /> SAN JOSE,CA 95123 v <br /> to DOLLARS <br /> IJ M 4 1., <br /> S.T.O THE ORDER OFDESCRIPTION <br /> NET AMOUNT <br /> SANTA TERESA-BERNAL <br /> l� • I � +^"�� <br /> �:t ? <br /> S. 0-CORSOLTATIONFEEs9b.u�u - <br /> 7. ❑ .PLAN CHECKING FEE ' . _ <br /> S. REAL ESTATE - <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address _____.__ Tele. No. <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 13 DLLs: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July + <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION OL <br /> PLUS <br /> PENALTY <br /> OTHER � <br /> OTHER <br /> Recened by Dale Receipt No Permit No - .�+=YQ Is—suar�:o Dele ailed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE..P.D.8 x 900Y STOCKTIfN a ns�m- -- <br />