Laserfiche WebLink
Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />ZIP <br />B'fhange of Owner □ Other□ Consultation □ Repairs or Remodel <br />License Plate Number VIN <br />□ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license number <br />□ Contractor □ Architect□ Property Owner□ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />zzDATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY/ BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDate <br />□ Check# <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 />ZIP <br />State^ <br />State <br />Type of Service <br />Requested <br />Comments <br />r. 12 <br />Email <br />Supervisor District <br />Application Form______ <br />NA cun cc Vbreocd LlC <br />$7^) 6^ <br />OPERATOR / MANAGER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this appli< <br />Standards, STATE and FEDERAL laws. A <br />APPLICANT'S SIGNATURE: <br />First Name <br />Address , <br />(Tor) 300- ^2- <br />□ Facility Owner <br />Last name <br />fA QQ z<r <br />Record Number ________ 5 ft 3,501733 <br />Confirmation # <br />L <br />$ _____ <br />Site Address y7.3 <br />APN <br />PE <br />Payment Z7) / <br />Received By/