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Applications Will Be Processed When Sub:,-Mitcl Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> VIRONMENTAL HEALTH PERMIT/SE. ES <br /> ENGINEER'S AND/OR 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 /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS Re 1st. NO. <br /> ;TRATION MISCELLANEOUS SERVICES g <br /> BER F�j Color <br /> /--6--Lf Date � —o / Business/Name To Appear On Permit <br /> FI Type Permit/Service Requested: D �—/� d <br /> i Applicant Name E 5 EAA"0AJ/�/��T�"� ddress r• C1 h/e y- ?2 Y2 �6720-Z /,S b- <br /> aBusiness Telephone No..9091; 3�-45! Emergency Telephone No. <br /> Property Location/Address LL 7706 i% �ligit/�� C'>< s�/y <br /> iProperty Owner�/�l t�/L Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ETS ENVIRONMENTAL <br /> P. O. BOX 2242 286 <br /> MERCED, CA. 95340 90-7061 <br /> PHONE 209-3841041 �— 3211 <br /> rl �7�1 S 190 11" <br /> PAYTOTHE C- j / �. /// <br /> ORDER OF �--�' t,r��L�/�L L DC�'t '��/l`L /S�s`J C I $ � <br /> Vz 11/ r✓ Dy DOLLARS <br /> Atwater Branch 16 <br /> UARAMWA 700 Bellevue Rd. <br /> SAVINGS Atwater,CA 95",101 <br /> A OM1SION Of riENDVE//FE➢EnH ,�/ ,/� <br /> FOR �L <br /> M11111,101 Tvaate vwNuaat Meutw <br /> 6.V Vim'CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <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 <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, andu s andegul do of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ✓ Title aeck5'/Sz' Date l ��77 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rved by Date eipt No Permit No Iss, Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENV, RENTAL HEALTH PERMIT/SERVICES 1601 E.HA .ON AVE.,P.O.Boa 2009 STOCKTON,CA 9520 <br />