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❑ New Facillty ""- <br /> 1 L'. artment <br /> 2 C�'uin County Environmental Health Dep <br /> q <br /> Application Foam <br /> Facility Name <br /> Englent Property ZIP <br /> City state 95240 <br /> Site Address Lodi CA <br /> 11808 N. Ham Ln. <br /> APN Supery or District <br /> 059-230-12 t7J <br /> ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel PAYMENT <br /> Type of Service <br /> Requested Operating Permit D <br /> Comments <br /> Review Soil Suitability/Nitrate Loading Study <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck EN SAN OA JH t-^ T— <br /> AL <br /> Contact Types i ❑Billing Party ❑Facility Owner ❑Facility Contact T❑Propery Owner ❑Contra L�H �Arequired I ENT <br /> N Billing Party ❑Facility Owner ❑Facility Contact ®Property Owner ❑Contractor ❑Architect <br /> First Name Robert Englent Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 11808 N. Ham Ln. Lodi CA 95240 <br /> Phone Phone Email <br /> (209)993-5549 1 iRob@sewersharkmfg.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner X Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Abby Racco Live Oak GeoEnviron mental, CEG 2151 <br /> Address City State ZIP <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209)369-0375 liveoak.enviro@gma Isom <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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. _ <br /> APPLICANT'S SIGNATURE: �_�-.. DATE: <br /> J�PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> / Title <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 /> Ac�d By Assigned To Linked FA ID -- <br /> Date PE Fee r i Record Number <br /> I <br /> Payment <br /> ❑Cash ❑Check# Confirmation# 12 j (� � j Received By <br /> '00 yew <br /> Rev 07/10/2024 <br />