WORK PLANS - Laserfiche WebLink

Home Browse Search

E^New Facility Existing Facility San Joaquin County Environmental Health Department Facility Name ^2 Site Address ac. APN Other Change of Owner Repairs or Remodel Consultation License Plate Number VIN Architect Contractor Facility Contact Property Owner Billing Party Facility Owner Architect Property Owner Contractor Billing Party Facility Owner Facility Contact If contractor, indicate type and license number State ZIP Architect Contractor Facility Contact Property Owner Billing Party Facility Owner If contractor, indicate type and license numberFirst Name Last name ZIPStateCityAddress EmailPhonePhone Contractor Property Owner Facility Contact Billing Party Facility Owner Last nameFirst Name StateCityAddress 20X EmailPhonePhone DATE: OPERATOR / MANAGER Title Linked PAIDAssigned ToAccepted By Kad-econn e L. / (VLRev 06/12/2024 If mobile food truck or pumper truck Contact Types required CZApplication for Operating Permit J If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Phone 7/Q5-Z-? 7^3 7 OTHER AUTHORIZED AGENT Type of Service Requested Comments State H Audiitect If contractor, indicate Iy|pti®’if£n6f yumoer W'7 / First Name //Last name 7^) 7 7 Addrcs^W M Phone Jeff C. Datefo | (11 zs Fee .Record Number ^P25(^2I8S ___________Application Form an ll/Q.r- £ ^// /v Mud Supervisor District PE __________________________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all si$¥Sr?^|f/yyject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. _ I also certify that I Ka^pr^ared ftiisappn^traH‘Jp31Fap(nework to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE ain cfepERAl/ Z7 "X / h— APPLICANT'S SIGNATURE: 7^ . ~------- ------_ DATE: (jT f _______________ □/PROPERTY / BUSINESS OWNER