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�i <br /> Appllcatlona Will Be Prociiaed When 9u AppLIPtOPOHY CATION p1e1ed. 0e Sur!to 31gM the ApplltAlloh. <br /> ENVIRONMENTAL HEALTH pP-RMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENOINEERS ANO!OR ►000 ESTABLISHMENTS.HOUSING Make <br /> APPLICANT S ANO/On PUBLIC POOLS.wATE11 SAMPLING <br /> CONTRACTOR ANO/OR ILEAL ESTATE INSPECTIONS Lic. NO. <br /> BROKER AND/On POULTIIT KANCHIS AND KENNELS Regist. No -- <br /> •,.cNSE AND/OR MISCELLAN 0111 SEH111ttll <br /> COIOf <br /> 1TRATION __------- --- - <br /> aER <br /> Application Dale <br /> -•// —9� Business/Name To Appear On Permit r /r�rcn <br /> r _. <br /> Type Permlt/Servlc Requested: 1� TDet9+� <br /> L O �/S©� /V, rJ >r <br /> Applicant Name eft/U--___. -- Address .2_ O <br /> f}-LV <br /> Business Telephone No. `J./5^ Emergency Telephone No!e! �y» Y7 <br /> -931=�-� <br /> 7y�vF Rd <br /> Property Location/Address.ys7 AsZ-1S�1- �— �8-6— <br /> Properly Owner L'��1L�1CLit�a--�# -rWI"---- Address —_ <br /> S/h/'/L4_ h!�"-5 F1 z t- 1i e-- _. Address r��,'�� -- <br /> I <br /> operator's Nem• Reelaurent, MaKimuln Seating t3apaelly <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> ❑ RESTAURANT 11 Foot) MARKET RETAIL ❑ FOOD MARKET WHOLESALE 0 BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY 0 ICE PLANT <br /> ❑ LIOUOR SCORE C3 BAR <br /> b ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND C] F000 VENDOR <br /> 13 CONFECTIONARY STORE 11 FOOD SALVAGER FOOD DEMONSTRATION d 0VENDING VEHICLE <br /> ❑ VENDING MACHINES/No, of d MOBILE FOOD PREP. UNIT <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees -ALL APPLICANTS: Total Employees Including Operators ------- <br /> 1. HOUSING R Af w cO j cl <br /> O HOfEL/MOTELO). of 01`1111 -----_._ <br /> ❑ MOBILE HOME PARK/No. of Spacee <br /> 3. WATER OUALITY 0 WATER SAMPLE (Bacterial) CHEMICAL <br /> PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY d WATER HAULER <br /> in,jr—anavcnin—...41-1-- <br /> PEN <br /> 2226 <br /> SIERRA HILLS PACKING INC. <br /> 4505 JACK TONE RD. 209-931-5157 <br /> ttOCKTON, CA 95205 90-103/121) <br /> PAY <br /> I TO THE / / rS. G : N•� 1. <br /> ORDER of 1' �, <br /> II C- um DO � t'„ ,;1 DOLLARS <br /> i.'Wo <br /> oquARTERi - 1 <br /> IM L Mink A"..fledda+,U Oft <br /> FoR - <br /> nB0022 'c511B 4o:1, LL >,01,037I: 2Li116g737411i0i <br /> /` Title lit_. _//1L a . - Date <br /> VIPPLICANT-S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IB DUB: ❑ ANNUALLY 1:1 En UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 A ReceiveRdEBAylTuly 31 <br /> -- EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> RASE �/ PATE DATE REMITTED AMOUNT <br /> FEE 1r J <br /> LESS ` <br /> PRORATION <br /> PLUS �j`1LGlG i — <br /> PENALTY <br /> OTHER <br /> OTHER I "1 <br /> _— —_---—— -- -_— , —Permrt No Iewrnce 011• Mailed Delivered <br /> Received by 011e RlcNpl No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES /�5 N. Sen Joa9uin St. P.O.Got 20M STOCKTON,CA fSt01 <br />