Laserfiche WebLink
San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Woodward Park <br />Site Address 710 E. Woodward Ave City Manteca State CA ZIP 95337 <br />APN Supervisor District <br />Type of Service <br />Requested <br />X Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel D Other <br />Comments 14 J 'E L.-0 ----€.. <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />X Billing Party 0 Facility Owner 0 Facility Contact Li Property Owner DI Contractor D Architect <br />First Name Kamal Bir Last name <br />Singh <br />If contractor, indicate type and license number <br />Address 1687 Bella Lago Way City Manteca State CA ZIP 95337 <br />Phone <br />2093260000 <br />Phone Email SIDHUPRODUCTIONLLC@GMAILCOM <br />D Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor D Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party D Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />I 1 I PPIAitt M E N T <br />ancRECEINED First Name Last name If contractor, indicate type <br />Address City State ZIPMAy 20 2024 <br />Phone Phone Email SAN JOAQUIN COUNT <br />ENVIRONMENTAL <br />DEPARTMEN <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />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, <br />Standards, STATE and FEDERAL laws. 5/14/2024 <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted By <br />0,"if,,,,_....., <br />Assigned To Linked FA ID <br />Date <br />S -0--- ?4-- <br />PE <br />I toiC <br />Fee <br />( () 2_ 0-- <br />Record Number rt p ja 400394. <br />pi, V 1C 6I V) ) t29 f V <br />RI) '617 \ '72/P 2K