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1N Applications WIII B*Cessed When Submitted Properly Completed. Lore To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Llc. NO ---- - <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Reg ist. NO. <br /> STRATION MISCELLANEOUS SERVICES <br /> I. .dER _-__— Color — <br /> [Application Date Business/Name To Appear On Permit - <br /> oType Permit/Service Requested: ---- - ---- <br /> Applicant Name Western Meter Address 2.7.35_ Teepee Dr. , Suite E, Stkn <br /> u _ Business Telephone No. Emergency Telephone No. <br /> J <br /> Property Location/Address 96055 AThornton .d , Thornton <br /> Property Owner Donna Gardner Address _ <br /> -Operator's Name Address <br /> T. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees I-Iw ino Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units — ;ATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spa <br /> 8. WATER QUALITY ❑ WATI <br /> ❑ PUBLIC WATER SYSTEM I• I <br /> NO. OF PUBLIC SERVED (Connect - <br /> 4. RECREATIONAL HEALTH ❑ I NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ PI - <br /> r :ENNEL/Runways ^ Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method— / <br /> Water Supply Source _. / 1posal Method <br /> 6. ❑ CONSULTATION FEE — <br /> 7. ❑ .PLAN CHECKING FEE — <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspecti <br /> Sewage System In! Tele. No. <br /> Escrow No. <br /> Seller Seller Au.'.- <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEE $35 Cancel TR 1024 89 $35.00 <br /> LESS <br /> PRORATION <br /> PPLUS <br /> ENALTY PENA r1rSM1111 RP PPLIEDTOP ST DUE ACC OUNTS 30 <br /> OTHER DAYS f BILLIN ' DAiE. <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> COPIESL— APPI CAMT-RETURN ALL O: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.So,2009 STOCKTON,CA 95201— <br />