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253 <br />-2/ /9 ell 90'7503 <br />3211 <br />$ 1c1 P e..e <br />c._ <br />ANCY <br />ng Capacity <br />MARKET <br />IAKERY <br />TINERANT RESTAURANT <br />DOD VENDOR <br />'ENDING VEHICLE <br />b z <br />z <br />! --I <br />- > : <br />PI 7E <br />-IING PLACE <br />, <br />' <br />r- <br />JAMES F. FRUMM <br />MARY JANE FRUMM <br />3678 MESA VERDES DR. <br />EL DORADO HILLS, CA 95630 <br />AEROJET C TER <br />FEDERAL CREDIT UNION <br />12519 Folsom Blvd., Rancho Cordova, CA 95670 <br />.C6r r.svek „6. C-rd.a fevo•cigrAr•-•••• • <br /> <br />APPLICANT'S SIGNATURE Datp Title <br />FOR DEPARTMENT USE ONLY <br />Date Receipt No. Permit No eived by <br />Applications Will Be I <br />ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />I('.ENSE AND/OR <br />3TRATION <br />I. .dER <br />ssed When Submitted Properly Completed. Be <br />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 ‘/Z/k, Business/Name To Appear On Permit <br />,n Type Permit/Service Requested. <br />Z Applicant Name 9;116721td-19-A-/ 6:::41(41-A1/4/671/70:0-e-- Address 7/9 l-iNtv/A. /4 je 6e.- 7 ,S2,/lt' so / <br />Q. - .534 - C 70 / 7i- - 7, 5 "r a 7 , Business Telephone No _64‘-') _,--• (7 /1(5-7 2— Emergency Telephone No <br />lc-Property Location/Address 4/4 /1.1/ CZ S. 5 2-/ee-2--- 1 , /4-7,tivreE <br />d Property Owner .8E—C/e.4)67' re...C.34We-71.77- Address /2/ZY (-)• /e7127/),e7L Z.974e---- .J-7-x:fr, 2-C2O`i / :I[g_ Operator's Name Address <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Suryjy Source Animal Waste Disposal Method <br />lit,--6ONSULTA1ION FEE Glidkk v/e6,2 //op <br />0 PLAN CHECKING FEE <br />REAL ESTATE <br />REQUEST: Water Well Inspection 0 Sample 0 <br />Sewage System Inspection 0 <br />Escrow No. <br />Title Company <br />Address Tele. No. <br /> <br />Seller Seller Address <br />Telephone No. Seller Agent Name <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 />Fee IS Due: 0 ANNUALLY 0 PER UNIT <br /> <br />0 PER SITE 0 EACH <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />__ _ .. -, - -- <br />$ <br />REMITTED <br />. _. , <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE >r 35' Weviei, <br />LESS PRORATION 4004et-/ <br />PLUS <br />PENALTY <br />OTHER )'P dr-: / ‘r#/z- <br />,-- , "1 z / <br />OTHER f_.\ <br />.7o `'`*- <br />a ..--- 7c., <br />A <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Issuance Date Mailed Delivered <br />1601 E. HAZELTON AVE., P.O. Bo: 2009 STOCKTON, CA 95201