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`MrG���I�D <br />sEP 1 7 Auld <br />BEFORE THE BOARD OF HOUSING APPEALS OF S IQWW1CBUNTY4 <br />� <br />APPEAL FORM <br />San Joaquin County Ordinance Code Section 8-5005 <br />In order to be valid, a written appeal must be received within thirty (30) days <br />of the mailing of the notification of the violation or demand for payment. <br />A $78 fee must be submitted with the appeal application (Board of Supervisors Fee Order B-92-1591). <br />Date: Premise Address: <br />Appellant's Name: Phone: <br />(type ori n <br />Mailing Address: % %�� J/� l/, , �� /��r�/, �0, <br />Legal Interest in Property: > Property Owner ❑ Beneficiary ❑ Lien Holder ❑Person in Possession ❑ Tenant <br />Type of Relief/Appeal <br />The findings of violations by the San Joaquin County Environmental Health <br />Department, as documented in the Notice dated— <br />San Joaquin County Ordinance Code Section 8-5102 <br />❑ The Statement of Expense for San Joaquin County Environmental Health Department <br />inspection and enforcement costs dated <br />San Joaquin County Ordinance Code Section 8-5401 <br />Give a brief statement, in ordinary and concise language, of that specific order, violation, or Statement <br />of Expense protested, together with any material facts to support the claims of the appellant. <br />Give a brief statement, in ordinary and concise language, of the type of relief sought and the reasons <br />why the protested order, violation, or Statement of Expense should be reversed, modified or otherwise <br />set aside. <br />Applicant's Signature: �2eu��%C�' lX Date: l� h <br />I CERTIFY UNDER PENAL TY OF PERJURY WA I T FOREGOING IS TRUE AND ORP. ECT. <br />Mail or Deliver to: Board of Housing Appeals of San Joaquin County <br />Environmental Health Department <br />600 East Main Street <br />Stockton, CA 95202 <br />For assistance call (209) 468-3420 <br />Date Received: I Program Record: <br />EHD 13 -XX 04/28/2010 Appeal Form <br />