Laserfiche WebLink
New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Mission Pizza and Pub <br />StocktonSite Address 5654 N Pershing Ave City State ZIPCA 95207 <br />APN Supervisor District <br /> Other Consultation Change of Owner Repairs or Remodel <br />License Plate Number VIN <br /> Architect BHHng Party Facility Owner Contractor <br /> Property Owner Contractor ArchitectH Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name KelleyTristen <br />Address City State ZIP 952075654 N Pershing Ave stockton ca <br />Phone <br /> Architect Billing Party Facility Contact Property Owner Contractor Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />City ZIPAddressState <br />Phone Phone Email <br />04/07/25DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br /> Cash Check*'/Received <br />Rev 07/10/2024 <br /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Email <br />Hightechchefifflgmail.' om <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 al the same lime it is provided to me or my representative. <br />Contact Types <br />required <br />^Confirmation * <br />Type of Service <br />Requested <br />Comments <br />President <br />Title <br />" I (oQgl <br />~ SB <br />"X-q-as <br />Phone <br />510 415 7842 <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 jawt. . zz <br />APPLICANT’S SIGNATURE: / <br />Assigned To I <br />'Ina <br />' °9 <br /> Facility Contact Property Owner