WORK PLANS - Laserfiche WebLink

Home Browse Search

1/5 New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name ■bonita?r U ZIP APN □ Repairs or Remodel□ Consultation □ Change of Owner □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number Address □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner If contractor, indicate type and license numberFirst Name Koi Phone tGv-v-t EfBilling Party □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberLast name Email DATE: □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT Title Linked FA ID Rev 06/12/2024 021^03^2- Contact Types required ZIP VIN ZIP Phone ■310 T'OO State ZIP Of Facility Owner Type of Service Requested Comments Email ■ '________________________________________ B'Facility Contact • (We fl Phone Site Address ______3SV AJ Supervisor District State Supplication for Operating Permit MFF N>ev3'(p(cin iZevieu)] If mobile food truck or License Plate Number pumper truck_________________3__________________________ City . Lc J. ■ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required • Q; y >. AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby autlaortzaihe/J release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.CO/j y-r- h Apartment Last name HI rr\ Goe Accepted By ,,Francisco K ■ $2-3124 Assigned To Francisco l< City L<-4-kr-op> City City $ /-t ■l4c--/-c-’ FiptName . .Last name SniArF SCr^ictAS Address t Phone Sid W n i oo State CA- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified 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. ' I I OL/ APPLICANT'S SIGNATURE: (J1" DATE: 1 I ' I ' IH/PROPERTY/ BUSINESS OWNER Last name- UserM pWi Address . IS~l^ S Phone 2^ First Name I _________ Phone Email 0Yl«l"4-S • CCr'*'! State