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Applications WIII Ge�'Ised When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION .►W <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED. GIVE <br /> ENGINEERS AND OR FOOD ESTAILISHMENTS.HOUSING Make <br /> APPLICANTS AND:OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS LiC. NO. <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. NO� <br /> .•-ENSE AND:OR MISCELLANEOUS SERVICES <br /> 3TRATION Color <br /> aER <br /> Application Date -93 Business/Name To Appear On Permit <br /> .sY 7�117f ,� <br /> rp1pa+Type PermivServic�aR�e�que�st�= ,�SC� <br /> 3A�IiDamName LO _ Address � J ,y�l.zel,)O <br /> ZJ �p tJ -r�¢ . Business Telephone No. <br /> ,e�f�--F✓-< -'�-- Emergency Telephone No. <br /> &Property Locationjj/��A,^1dndJr�-e-^ss,��.ys��� �- - ��.5'- J <br /> i Property Owner.C��/jam/4CK_ � --"_CD Address <br /> S/l-/: -. -LS ��/tZ.k /NG— Address -�TUCx <br /> \�I Operator's NemA Reeteurenl.MaNlmurn SAaling 62PAe11y <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ COMMISSARY <br /> 11 ICE PLANT ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ BAR 0 ITINERANT RESTAURANT <br /> 11 ROADSIDE FOOD STAND CI LIQUOR STORE 13 FOOD VENDOR <br /> ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ VENDING VEHICLE <br /> 13 CONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT <br /> 13 VENDING MACHINES/No. of --- <br /> ❑ FOOD CROP HARVESTING/NO. of Field Employees ---' <br /> ALL APPLICANTS Total Employees Including Operators_------- <br /> 1. HOUSING R ppTIFRF IaPOH MGY <br /> 0 HOtEL/1,101€L/Nd of WWII -- . <br /> ❑ MOBILE HOME PARK/No. of Spaces _ — <br /> �3,.. WATER QUALITY I7 WATER SAMPLE lBacterial) ❑ CHEMICAL - <br /> 1cY PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER _ <br /> _DF_P11RI <br /> 2226 <br /> SIERRA HILLS PACKING INC. <br /> 4505 JACK TONE FID. 209-931-5157 <br /> STOCKTON. CA 95205 23 90.10YI211 <br /> r <br /> PA <br /> TO THE /47 'j G 1'd E/ I I $ <br /> } ORDER OF <br /> TF)E $UMI? T T jJ 4r ;,,1 DOLLARS <br /> Bank n <br /> HEADQUwas <br /> s <br /> Yet E Mi.Ave..I*m10 y CA 2010 <br /> FOR <br /> 9'00222611' 4: 123, 1010371: 2LFr16873741P0i <br /> ` Title �� Date / 52 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY 0 PER UNIT 0 PER SITE 0 EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received ByT <br /> eceivdyl July 31 <br /> REM <br /> TION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> ANA <br /> BASE E ANA �F DA DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Glwu� l!J <br /> PENALTY <br /> OTHER <br /> OTHER <br /> RaAPAy Dale <br /> Receipt No Permit No Beaune DLtoo Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 445 N. sen•TnArlrLn sc. oo.eo.no STOCRTON.CA 95101— <br />