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BEFORE THE BOARD OF HOUSING APPEALS OF SAN JOAQUIN COUNTY APPEAL FORM San Joaquin County Ordinance Code Section 8-5005 In order to be valid, a written appeal must be received within thirty (30) days of the notification of the violations or demand for payment and the $78 fee must be submitted with the appeal application. (SJC Ord. Code Sections 8-5102, 8-5403, Board of Supervisors Fee Order B-92-1591) Date: Premise Address: Appeal of: Phone: (type or print Appellant(s)name(s) Mailing Address: Legal Interest in Property: ❑ Property Owner ❑ Beneficiary ❑ Lien Holder []Person in Possession ❑ Tenant Type of Relief/Appeal ❑ The findings of violations, the findings to vacate, or the findings to relocate tenants by the San Joaquin County Environmental Health Department, as documented in the Notice dated San Joaquin County Ordinance Code Section 8-5102 ❑ The Statement of Expense for San Joaquin County Environmental Health Department inspection and enforcement costs dated San Joaquin County Ordinance Code Section 8-5401 Give a brief statement, in ordinary and concise language, of that specific order, violation, or Statement of Expense protested, together with any material facts to support the claims of the appellant. Give a brief statement, in ordinary and concise language, of the type of relief sought and the reasons why the protested order, violation, or Statement of Expense should be reversed, modified or otherwise set aside. Applicant's Signature: Date: 1 CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Mail or Deliver to: Board of Housing Appeals of San Joaquin County Environmental Health Department 1868 East Hazelton Avenue Stockton, CA 95205-6232 For assistance call (209) 468-9674 Date Received: Pro ram Record: EHD 13-XX 05,'10/2012 BOHA Appeal Form