WORK PLANS - Laserfiche WebLink

Home Browse Search

Existing Facility San Joaquin County Environmental Health Department State APN Consultation Change of Owner Repairs or Remodel Other Billing Party Facility Owner Facility Contact Property Owner Contractor Architect /^-Billing Party Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberLast name State Billing Party Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last nameftr0 c-€| i Address State Phone Contractor Facility Contact Property Owner Facility Owner Last nameFirst Name City StateAddress EmailPhonePhone JE: Title Linked FA IDAccepted By Fee 1 Check ft Cash Rev 07/10/2024 7 OTHER AUTHORIZED AGENT Contact Types required If mobile food truck or pumper truck Date z City Email ZIP 7 y SV6 Type of Service Requested Comments Phone /iM-SUO-C/ZTy Facility Owner Phone Billing Party (^\v\oh c-'h Email facility Name Site Address City swwwi 11 ~ I fx-eSh Assigned Toi ex- ^Confirmation # ___________Application Form ToKli ll-evfo- Rcy-S Supervisor District ^PROPERTY/BUSINESS OWNER ^OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required APf) AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site afitiWlss^ release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUtfJ^NVIRONi DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.Pkh^QUikj First Name P6 h i Address IZ^A-C/h C/Y Phone City Record Number _Z) pzea i q -4 9______ Payment TH Received B\L/d- O New Facility ZIR<? 5 20 C PE , 1^0/ s/h(*»eby authorize the N MEN WEALTH ^Application for Operating Permit License Plate Number Facility Owner Dflnit I S _____________________________________________________________________________________________________________ ,'ij --------------------- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that'afrsiU; giteVpr project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as idenVifi’At^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. J . ' ) APPLICANT'S SIGNATURE: ^OPERATOR / MANAGER Architect If contractor, indicate t\^ ^nBffqMfcnumber I' ?3 ^25 nVifTfi^on this