Laserfiche WebLink
^Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />f-y, (>t'~ <br />ZIP <br />APN <br />^Change of Owner □ Repairs or Remodel □ Other□ Consultation <br />License Plate Number VIN <br />□ Contractor □ Architect□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact <br />JBJlilling Party 0 Facility Owner /& Facility Contact □ Contractor □ Architect□ Property Owner <br />If contractor, indicate type and license number <br />StateAddress <br />Phone <br />□ Architect□ Contractor□ Facility Contact □ Property Owner□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />>jfi be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,and that the worl :o be jiei irmi <br />/ C DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />^12. <br />Rev 06/12/2024 <br />90^0$ <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <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 ai <br />Standards, STATE and FEDERAL laws. ( <br />APPLICANT'S SIGNATURE: ________/ <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 />Supervisor District <br />City <br />Phone . ' <br />____G- <br />Type of Service <br />Requested <br />Comments <br />Email <br />J> 6? At/1 C- < <br />Linked FA ID <br />Record Number <br />SR2H <br />Last name y <br />kCity <br />i Fee$H2 (Z<D <br />First Name <br />/<z^yv^vz <br />i g>- <br />WilmM |re 190'2- <br />If contractor, indicate type and licens/r^fli^ii] <br />If contractor, indicate type and license number <br />State <br />Facility Name <br />___________ZIz/a/vV'jZ- /-"_5 <br />Site Address