Laserfiche WebLink
Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />State <br />Supervisor District <br />^J^hange of Owner Repairs or Remodel Other <br />e\r\< <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />; L c ( <br /> Billing Party Facility Owner Facility Contact Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone EmailPhone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />in and th; <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Title <br />Assigned ToAccepted By <br />Fee <br />-\ 2- <br /> Cash Check fi <br />Rev 07/10/2024 <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <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 />Phone Phone <br />ie work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />ZIP <br />Date <br />■a -2-5 2 5 <br />Type of Service <br />Requested <br />Comments <br /> Contractor <br />LSr>Wxr <br />PE <br />If mobile food truck or <br />pumper truck <br />Linked FA ID , <br />Record Number <br />SK25CD <br />Vconfirmation » \ H <br />A <br /> Consultation <br />2 <br />License Plate Number <br />City <br />"yr <br />^Billing Party <br />First Name <br />Address <br />Email VL(_ <br /> Property Owner <br />VIN <br />City <br />ZIP <br />Application Form <br />Site Address <br />APN <br />State c A <br />If contractor, indicate type and licensM^f)|/|*»i>J <br />,/tus,. 60 <br />—BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or pfR^n^y- <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 aj <br />Standards, STATE and FEDERAL laws.^ <br />APPLICANT'S SIGNATURE;iStf^—7^;