Laserfiche WebLink
New Facility Existing Facility <br />Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Property Owner Contractor Architect <br />'^fijilling Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />City State ZIP <br />Phone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />DATE: <br />^PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Linked FA IDAccepted By <br /> Cash Check ft <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />Application Form <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Payment /i <br />Received By ( ! <br />License Plate Number <br />Type of Service <br />Requested <br />Comments <br />/V i <br />Email <br />V'N <br /> Facility Contact <br />Je f F _C. <br />PE <br />(^Application for <br />Operating Permit <br />La^tname <br />Assigned To <br />i P. <br />Fee <br />/7 Z- Q)d> <br />/C- i <br />j City <br />Fjrst Name /J <br />Address <br />no0 <br />Phone <br />-8Z3 / <br />State * <br />Date . . <br />05//Z/25 <br />Facility Name , <br />//?// <br />Site Address, , ■ . T —. <br />/O I > S /&) <br />APN <br /> Contractor <br /> <br />If contractor,number <br />_ ____ .ML2 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge7tRSt MWfi^d/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. <— t C <br />APPLICANT'S SIGNATURE:^ DATE: ~ <br />Record Number <br />Confirmation It 2011^3