Laserfiche WebLink
Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address Sr <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Contractor Architect <br />TfikBilling Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license number <br />Address ZIP rzo? <br /> Property Owner Contractor Architect Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />Address City State ZIP <br />EmailPhonePhone <br /> Contractor Architect Facility Owner Facility Contact Property Owner Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />StateCity ZIPAddress <br />EmailPhonePhone <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned To <br />dll ^1.^Fee <br /> Check ll <br />Rev 07/10/2024 <br />0020^2 <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required MAR 2 7 202S <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/slte assessment information to the SAN JOAQUIN COUNTY ENVH-: 3ANr JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ENVIRONMENTAL <br />. HEALTH DEPARTMENT <br />i I <br />Facility <br />C!' <br />Application Form <br />Ooj> S' <br />C"VS1'acfK^State .CA <br />1 Property Owner <br />s,a"cA <br />fllekt,__________ <br />Wy i?;ry aa/ <br />Phone Phone EmailS~/62-| qAeTrjp. Malfoo l/fc 60 <br /> Billing Party <br />Do^s_ <br />S t forri/c, <br />Supervisor District <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 />ZL-X—:---------------DATE: 7/2 Z/2/ <br />Property / business owner <br />Payment A/ / F”? <br />Received By^[/(/ <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />’ Ont, <br />tB Confirmation It 'O I <br />ZIP ? T202- <br />iW L <br />’ I Mt <br />c^r <br />I VIN <br />K Application for <br />Operating Permit <br />Poc a <br />License Plate Number <br />Accepted By t » (L <br /> Cash