Laserfiche WebLink
New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />ZIP <br />APN <br /> Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />State <br /> Architect Contractor Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />HiEmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />FeePE <br /> Check ti <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />JZfApplication for <br />Operating Permit <br />Type of Service <br />Requested <br />Comments <br />Assigned Tqf <br />:ation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />state <br />"The "Tarm1 <br />slteAddfe7^ IT <br />Supervisor District <br /> Cash <br />Email <br />IP Q/NmI- C(yrv\ <br /> Property Owner <br />J. ( CK <br />Last name . . <br />If contractor, indicate type-aod license numrorW <br />_____________________ __________________________________________________ <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 appfrca'.---------— ... <br />Standards, STATE and FEDERAL laws. A' <br />APPLICANT'S SIGNATURE: /' — ■" <br /> OPERATOR/MANAGER <br />Confirmation | Received By <br />“1,~ /a? <br />Phone