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Kishng f-itrllitvFl New f-arllity <br />/•San Joaquin County Environmental Health Department <br />r.xihi, Nuuie <br />Site AtMmv <br />Al’N <br />Jli/ppik jlKin foi noth.-. <br />Comment-. <br />^ifF*cthtY Owner CJ I’K'iH-tly Owner I K ontrMtorIJ fwlMy ConlXt <br />IJ t jntr.Kto>jjCfeti’Ity Ownery Itilimi: Party t.J ArchitectII property OwnerIJ tai-irtyContait <br />It ctmlrunnr, .ndryair type .rod lirume mirnlier <br />Stale <br />M-xkct <br />I) Contractor U Architect <br />it i rrntr.irior indicate ivre- jnn licamenumberFir-.t Name Ij-.t famr <br />ZIPStatetrtyAltrlr e <br />PbcnrPhone <br />\ j I ai. Hy Contatl. 11 aoIlly Owne<I I umi-rg Patty I ) ArrhitrrlU Contiactir <br />n contractor ndrcote type amt licente numbeiI trat Narne att nam. <br />ZIPStateCityArtrlrrtv <br />PhoneI'hnnrr <br />'l tbit <br />DAU <br />.nmiy I ftVSlNf SS < iWNf IJ.' , z ( J OllifH AUtHORI.'fO AGEhtI • OPEPATOfi Z/.tANAG'F <br />Anlgned ToAccepted By <br />7 <br />Confirmation* Check • <br />R.’yfl.'/UWOM <br />PAYMENT <br />RECEIVED <br />SEP I 5 2025 <br />tfreiv^ <br />T Phorir <br />Svpe»viw« <br />Il rnoDili* IijckJ ffuik or <br />pumprr true» <br />SAN JOAQUIN COUNTY <br />environmental <br />HEALTH DEPARTMENT <br />I ypo of Seivlce <br />HectueyterS <br />Contact Tyom <br />ren-nrerf <br />O ChrtnifC nt Owni'i <br />.•IPState <br />C0 <br /> <br />yM/pptkation foi Comultation ....., ... ... .. . <br />Opcrab'1* y 4* / / / • \ <br />| Ih.-iim- PlateNurnbyQ <br />(Jlllrl'i Party : I Archltrr.l <br />.11)^ <br />fl Fb’prtir v <•» Brmod#:l <br />j J ProiHMty <br />U C *>h <br />| kJ Facility Owner <br />mu ING ACKNOWlIDCCMtNT: I. the undrriinned ptcpftjlf ot buvnett owner, operator or aut'tor./M agent of ome. acknowledge that a'l >'tc and/or project <br />ypccilrc (NV'RONMf NT At »lf MIK MPARTMtUt rjn.y^iurf,.-. y .. utc.1 with Um project nr jrt.rnty w Ire b-tlert tn in. • niy bulincv. .ry>:li ■■ trlirrl or ttu <br />form <br />I alco Cc'ctrfy tl’.tl I nave p'eparcil tiny .i|Jtiftc.>VO'| <br />Stanrlairw, SIAH and (IOI KAI i tw. <br />APPUCANT'S SIGNATURE < <br />Il APl’t'i AN1 I', not the HllUlWi PAftlV, proof nl ,...lhoi..Z. 0 trumn o .rri.i.red <br />AUTHORIZATION IO Rill AM INFORMATION When a|l|»ll.‘able. I th.- owryi't or m>rralor v' Ihr iircperty l.yiatcd at the above 'air' addreit. Ir ■'.|>y authotUC lire <br />te.r-n’rc o’ any anil al. irMilty, geotechr'ical data inci/O' rnyiroftrncntal/yrli- acscownent iriformaiion to the SAN JOAQUIN fOUNTV I NVIRONMt NFAI .i| Al1r> <br />ElLPARtMINI a. woo at It n ataiialrlr ami at the Mme tune II It provltlwl to me or my rr|»ec»nlata>e___________ <br /> <br />/u>2_; <br />k to Ur- perfcrcncrl w.n be door n i<corclance with all S/yy ifJAOluh) < Oi.NTt Ordinance Corley <br />^33 7 <br />...... <br />1-^ V^J<n ■ ■ ■ ------------------------- <br />I rvusdx/ I ft <br />IJ Facility Contact | Property Owner <br />(mail <br />| I . i <br />Application Form <br />Adf(rv\* <br />.3^1 <T ; <br />Phon* <br />\(2^yto^ ‘iW, <br />rtTBJtrng I'arty <br />T... Ffi oooo£o^ <br />2o36AS505t ....... <br />.........