Laserfiche WebLink
New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address City <br /> Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Facility Contact Property Owner Contractor Architect Facility Owner Billing Party <br />s^Billing Party J^Facility Owner Property Owner Contractor Architect Facility Contact <br />If contractor, indicate type and license number1 <br />State ZIP <br />Phone <br /> Contractor Architect Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberFirst Name <br />State ZIPAddress <br />Email <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />zDATE: <br />Title <br />Linked FA IDAccepted By <br />Fee <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Payment <br />Received By <br />Phone <br />• i4i: <br />ZIP <br /> Cash <br />Daterz <br />State <br />^Change of Owner <br />C' <br />Phone <br />APN <br />Type of Service <br />Requested <br />Comments <br />Email <br />Supervisor District <br />I <br /> Application for <br />Operating Permit <br />^mail . / <br />0'facility Contact <br />(Bl^nfirmation # <br />Last name_^^ - A. <br />Cit>’ <br />Phone ~ ,-4c^>-<gg6-<ri% <br />First Name <br />tKio <br />Address <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. I / /'■> / A <br />APPLICANT'S SIGNATURE: / DATE: 7/ £ -----rpZ^nt <br />©Property/business owner operator/manager other authorized agent <br />^h&££by aut/ori^^4 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />PF <br />16? cU <br /> Check # <br />Last name <br />If APPLICANT Is not the BILLING PARTV, proof of authorization to sign is required 3 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addtf^tyhj <br />fZl <br />Record Number __ <br />I ^5^238^