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253 <br />90-7503 <br />3211 <br />JAMES F. FRUMM <br />MARY JANE FRUMM <br />-3678 MESA VERDES DR. <br />EL DORADO HILLS, CA 95630 <br />gliret.9/:5;.it $ <br />AEROJET C TER <br />FEDERAL CREDIT UNION <br />12519 Folsom Blvd., Rancho Cordova, CA 95670 <br />.Ciit mos ,* /4... &ow... c.c.. Ma... <br />- <br /> <br /> <br />APPLICANT'S SIGNATURE Title <br />FOR DEPARTMENT USE ONLY <br />Applications Will Be <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />IrENSE AND/OR <br />3TRATION <br />.dER <br />)ssed When Submitted Properly Completed. Be To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No <br />Color <br />[Application Date LiL.j Business/Name To Appear On Permit <br />to Type Permit/Service Requested: <br />„I Applicant Nagle /711g/2(e•-/9/1-, 6.7-41(4,--A1,10117:4?-- Address 7/9 Z/A/0634-' W4,7 6e- 7 Sci* -Cc,/ <br /> <br />3A-c/3' 7S12-? , Business Telephone No (4s4‘-') ,--..`71-kg-7 2— Emergency Telephone No. / <br />li Property Location/Address //11/e2 .S 5 "iiee-2--7 <br />d Property Owner L?&—Cit.- 4 )6;7- /6..-qe.)Poe,e71/ <br />/ <br />/ Address k27/4/ ,.(..)• /171,4279142e7L, 7,974,e2- StX.d.t.,_.- ,,‘.-2C.),- <br /> <br />1 Operator's Name Address / <br />ng Capacity <br />r MARKET <br />IAKERY <br />TINERANT RESTAURANT <br />:000 VENDOR <br />/ENDING VEHICLE <br />rn <br />! b z <br />rn L51 <br />(7; <br />> <br />1— <br />(m) <br />HING PLACE, <br />)ANCV <br />C--.- c <br />Sewage Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supoly Source Animal Waste Disposal Method <br />0 PLAN CHECKING FEE <br />(-tioR,elo/a"— te Vieto t.-m4-ffir 6. ONSULTATION FEE , <br />REAL ESTATE <br />REQUEST: Water Well InspectionD Sample 0 <br />Sewage System Inspection 0 <br />Escrow No. <br />Seller <br />Telephone No. <br />Service Request For Date <br />I hereby certify that I ha e prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, d rules and regulations of the San Joaquin Local Health District. <br />Title Company <br />Address Tele. No. <br />Seller Address <br />Seller Agent Name <br />_77 . Date /I /Af <br />0 PER UNIT Fee IS Due: 0 ANNUALLY 0 PER SITE 0 EACH <br />BASE EXPLANATION BILLING <br />DATE <br />, <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />_. <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE e 35' Wrvie <br />LESS PRORATION <br />PLUS <br />PENALTY <br />OTHER ?F/ 35-‘'''—' t5r-/k- <br />OTHER <br />, , , <br />C- C.'. <br />7o <br />....... <br /> <br />2 d <br />eived by Date Receipt No Permit No <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Issuance Date Mailed Delivered <br />1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201