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San Joaquin County Environmental Health Department <br /> Application Form <br /> Fac1lKV"Pre � � <br /> Slte �,. 5 - Ctir �C C� State __. IIP S .G. <br /> APte Supcltnwr trrstrkt <br /> Type A fierYLce Appbr i0an fc+ C.onusltatlo'r Q Change al Owner Q"*s w Remodel Owt�hfrr� <br /> R�puC0lad mating Prcrnit 1"�/� <br /> comments <br /> N otoErte fond trudr yr Lrmnx Plate Mumts¢r �� <br /> pumper ln,ck <br /> 4.�-�La:17;per W�ling:arty QE20IRYOYme! Qfactkty Cbmatt QProPerlY Owner Q(amlra[tor QAmhrtect I <br /> ' regared I {I <br /> 114 <br /> o-iL"g Perey ❑tartfdv t)woer ❑tariirly Contact C]ProperiY Ueme! QCortractor QArchitttt <br /> r,;.t�G.. l,.n,l nmar• 11 cortractor-Ind1cate type and kienw number <br /> Sic —r 4 5_ 1f Stale CC <br /> 0 Md!M Party ❑farsltly Owner l Ll r-Acuity Ctmtact 0 Preperly Owner C7 Contractor ❑Architect <br /> fa<yt Valk W.t nrc-e If conttattor,04144ie typo"licesrw number <br /> A6dreSS .. f,7ty State ZIP <br /> f I <br /> Q 8g1N'4l Party s t7 EaaMy Dwrer ❑iacAdr 17 Property Owner ❑Contractor C Archkect <br /> Fvtt Name ' last game 11contractar,indicate type and Incense number <br /> f,abyr<is�. Cyr.; Statr Zip <br /> �- Nhane 'mail -- — <br /> �eID16 ACK1al3yYtE06tM1ENT rhl te•-dnrs+gned paper us!vess ewner,operawr ar authrrrzed agent cd ante,acknowledge that alksife arrcE/er project <br /> spectAc t*AKINMENTAt WAIT H DEPAtiTUENT rg--s IL 06ated aeib thu pro>ect or activity will be Wk•d to me a my business as idenWfird on th6 <br /> i boon <br /> I also cr.tAy that Twee prepared t?" xt at work to be perfvrmed toll be done in accordance wal,all SAN AQU, COVN1y Ordinance Codes, <br /> Standards,SYA71 a+d FMKA bws. r'- <br /> AMCANT PGNATURE. o" OAfE. <br /> L/MffRTY1 MANESS R ©O OR/MANAGER ❑011il R IMHOSILEp AGLNr <br /> T,tte <br /> rf A PPvtAh T on,7ir !MLNG?ARTY,paeot Ct Lix3rtl3t30n 10 s>fn iS•';.sired <br /> AUT1fOR]ZA RELEASE WORMATW& tree a�pGcta3e,1,the cwner or opv,,tar o1 the prap[tty located at the above site addr"%hereby arutherize the <br /> ilefea se:f:n�y as r«salts.BeJte:hniCM cat zjWer fnvirawavntaVrte asst'ssmert WOMUtlon 94 the:AN 4AOUIN COUNTY EN%40NMENTAI HEATH <br /> 10 aAaTIMN aT s sawn u:t a xa.latrle and at d+e sa.-te tme K o o+ded to the to rs+y rrpreur..tatnec._-- <br /> Mieptrd By Assigned To ry Onked TA Vll <br /> 0 'Ile <br /> PAYMENT <br /> RECEIVED <br /> 2S �� VnV 0 4 2024 <br /> 3AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />