WORK PLANS - Laserfiche WebLink

Home Browse Search

❑ New Facility Q Existing Facility San Joaquin County Environmental Health Department Application Form P(� 05 --!3 -5 Facili Name V inCo Food Store#103 Site L sIpavilion Parkway City Tracy Stat ZIP to 95304 APN Supervisor District Type of Service ❑Application for ❑Consultation ❑Change of Owner ENRepairs or Remodel ❑Other Requested Operating Permit Comments Plan Review for T.I. to replace cases and related equipment in the Service Deli and Seafood Dept. If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party IX-Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 1211-Architect required ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect F t ame La a If contractor,indicate type and license number Petersen Staggs Architects - Dawn. tarfwelI Address City State ZIP 5200 W State Street Boise ID 83703 P'0268345I462 Phone Email L dawn_C@psarch. om ❑Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number WinCo Foods, LLC Ad MCity State ZIP N Armstrong Place Boise ID 83704 Phone I Phone Email 2083770110 ©Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. — �� September 3, 2025 APPLICANT'S SIGNATURE: =`��^y'� Q l DATE: p ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER CFOTHER AUTHORIZED AGENT Architect Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assign d T4 Linked FA ID L. O`if e-cs :F f::�-002 O S S Date -3 2 5 PE 1 b O Fee 5 3 4— Record Mu�eS JJ Yn� L Payment ❑Cash ❑Check# )5�onflrmation# 2.ram(O�S9 Sb Received By Rev 07/10/2024 �)