Laserfiche WebLink
New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Phone a <br /> Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIPCity <br />EmailPhonePhone <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked PAIDAssigned ToAccepted By <br />Record Number <br /> Check it <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <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 />Date <br />4- -1 (o ~ 3-Cr? <br /> Cash <br />City <br />li/ation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> DATE: <br />ZIP <br />ZIP <br />State <br />State <br />Phone <br />925 <br /> Existing Facility <br />Type of Service <br />Requested <br />Comments <br />\ ( Q_____________ <br />City <br />6TOC k~[ O O <br />. or <br />Lajt name .First Name <br />Address <br />Cm4^ <br />Fee4>H9 <br />VIN <br />iioc £oo6zqn4o4 3<?o^ <br />Te-PC C. <br />Application Form <br />Site Address <br />Supervisor District <br />License Plate Number <br />------------ <br />~ ' 1 ______ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackrtMlfadg^that alMterand/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my buslne^'ii'j^t^ied on this <br />form. <br />I also certify that I have prepared this. <br />Standards, STATE and FEDERAL laws^ <br />APPLICANT'S SIGNATURE: <br />~ ^Confirmation « ^2? ReSd By <br /> Architect <br />If contractor, indk^^ty|fember <br />— <br />(Qu rr tn Ox <br /> Property Owner <br />APR / ;■