Laserfiche WebLink
New Facility ® Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form - (\eeA7 <br />Facility Name Chapter 2 <br />Supervisor DistrictAPN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license number <br />Phone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIPCity <br />EmailPhonePhone <br />DATE: <br />(X PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />Tille <br />Assigned To <br />Fee <br /> Cash Check tt <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 />Application for <br />Operating Permit <br />City <br />Tracy <br />Site Address <br />88 w 10th St <br />Email <br />mrbradswest@gmail com <br />ZIP <br />95376 <br />First Name <br />Brad <br />City <br />Manteca <br />Date <br />25 <br />State <br />CA <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 i 9/8/2SAPPLICANT'S SIGNATURE: / . J nArc- ' ' <br />^Confirmation tl <br />Type of Service <br />Requested <br />Comments Catering Permit <br />If mobile food truck or <br />pumper truck <br />Address <br />2044 Brocchini Ln <br />Phone <br />209-740-7651 <br />ZIP <br />95337 <br />Linked FAjn <br />Payment <br />Received By <br />Last name <br />West <br />Rev 07/10/2024 , <br />Accepted By <br />L-k (xVxo^f-e_s____ <br />PE <br />State <br />CA