Laserfiche WebLink
EMAI LED ❑ New Facility ❑ Existing Facility <br /> 2 <br /> San joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Pham Property <br /> Site Address City State ZIP <br /> 4440 E. Cherokee Rd. Stockton CA 95215 <br /> APN Superv' or District <br /> 087-090-02 y <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel N Other <br /> Requested Operating Permit <br /> Comments <br /> Review Soil Suitability/Nitrate Loading Study <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> DQ Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Octavio Medina , <br /> Address City State ZI P <br /> 6156 E.Ashley Ln. Stockton CA 95212 <br /> Phone Phone Email <br /> (209)470-9028 plansandmore4@grtiaii.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N 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 ZI P <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209)369-0375 --Tlliveoak.enviro@gmail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Arc <br /> 7. <br /> First Name Last name If contractor,indicate type and 1 u I,I <br /> EF <br /> Address City State ZIP O v <br /> ZAAU <br /> Phone Phone Email ENVI�O USN COU <br /> Af <br /> IAI <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or <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 EN <br /> form. <br /> I also certify that 1 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: oc 7e� DATE: 5-1-26 <br /> ❑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 /> Accepted By Assigned To Linked FA ID <br /> Date PE O� Fee ,04yto'C'U Record NumberSV—rt 6O 13 )2- <br /> 2,�-x/'3�7 Payment <br /> ❑Cash ❑Check q Confirmation# v Received By <br /> e <br /> Rev 07/10/2024 Q,l�i�/ C• Q /.A c9�1�B'J •S'f- �/^�LQ <br />