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' F-viVIRONMENTAL HEALTH PERM IT/SERV1%,-S <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPpLLSJ1MB�9A-.� FOOD ESTABLISxMENT8 NOOSING Make <br />„ �E`BNTRACTDR III�GR'' PUBLIC POOLS WATER SAMPLING <br /> �B�r�KE�ANDIO — .. - REAL ESTATE INSPECTIONS <br /> .I .F-NSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION��/� ^ ' MISCELLANEOUS SERVICES Regist. No. <br /> I. .aER '71s:Z > Color. <br /> Application Date Business/Name To Appear On Permit <br /> �e Type Permit/Service Requested: <br /> .(Applicant Name.-- Q IGk "3okl r3c'� <br /> --_ Address— <br /> Business We{�hone No. Emergency Telephone No. <br /> Property Location/Address 16r—) V U-Q-Vi GO +�� '1 Yc•-« _ <br /> Property Owner LR> IZ 342 u Liz S!C5._ Address ;CSU <br /> STBANK In 13 �- - _ M RNI� <br /> sro R.FIRio;0"" <br /> _-. i t CALIFO <br /> r ni °� Ia���IS�.�N:ENDUStRiES .INC ,{ n >ao as I 3 1. <br /> 1 !! + 7 p 1 ,� ki f "- aeswrrr war„;000 ow�v* •rocurYa ,ew •a�aa + t t f�. <br /> Ir I , .. , .• 5r t i Ir l i - r >ItRO^�# ']tom <br /> 1� "{! 's t ; f'iQ41 S:•PE:ASHlNQ AVE: ! i �� _ : - I '`�-(}� <br /> 4i' 4 . STC]CKTON,CALIFORNIA 96206 ` I <br /> 7 + � <br /> rS"C—j:�ll }` <br /> 1 I i 1{Ml. <br /> f , <br /> PAY 7, 7i Q0 PAT$ <br />' 4, ly U �.l ' { "`ail :II^'"'-li •yl- �l—T'.i��: .,....r, :r3"�. "..-i.l,'"! ."� i.;i^�^1{ ,w.br +r r,,,.. +>,� , _ <br /> r Wk <br /> 1 + <br /> 1 I r' li it1G� <br /> SCIS ND T IE <br /> r "t7 <br /> - I ` it7 t <br /> _ <br /> 6.�6'iC;NSULTATION FEE W c-. <br /> 7. ❑ PLAN CHECKING FEE <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seiler 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 I <br /> ordinances, state laws,anles an regulations of he San Joaquin Local Health District. <br /> '0;�U:APPLICANT'S SIGNATURE X,17C Title Date ��— 3 6j <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 s <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> v� <br /> FEE <br /> LESS <br /> PRORATION I <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a <br />