Laserfiche WebLink
PROPERTY / BUSINESS OWNER 111 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQULST <br />Type of Business or Property <br />COMMERCIAL FOOD STORE <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR TASTEFULLY LLC dba HAPPY LEMON CHECK if BILLING ADDRESS 1 <br />FACILITY NAME HAPPY LEMON <br />SITE ADDRESS 1338 <br />Street Number <br />E <br />Direction <br />YOSEMITE AVENUE <br />Street Name <br />MANTECA <br />City <br />95336 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE tl EXT. <br />( 650 ) 307-3031 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR NGUYEN NGUYEN CHECK if BILLING ADDRESS 1 <br />BUSINESS NAME TASTEFULLY LLC dba HAPPY LEMON <br />PHONE # <br />( 650 )307-3031 <br />EXT. <br />HOME or MAILING ADDRESS 1338 E YOSEMITE AVENUE FAX # <br />( ) <br />CITY MANTECA STATE CA ZIP 95336 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,ST ATE and FEDERAL laws. <br />Title PAYIVItNT <br />RECEIVED <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site aApitlinq 2023 <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />SAN JOAQUIN COUNTY <br />provided to me or my representative. ENVIRONMENTAL <br />RTMENT <br />EHD 48-02-025 <br />REVISED 11/17/2003 e cvt-c 4k-l&it62:2 2278 <br />i/34(?12 1/) <br />SR FORM (Golden Rod) <br />TYPE OF SERVICE REQUESTED: NEW FOOD STORE PLAN CHECK <br />COMMENTS: <br />Requesting plan check for new food store (boba restaurant). We will do a commercial T1 for a boba shop. Existing office <br />space converting to boba restaurant. No hood needed. <br />For plan technical questions or comments, contact designer/architect: Glenn Cunningham, 510-301-3005, <br />glenncc@att.net, and copy us at tastefully.11c@gmail.com. <br />ACCEPTED BY: C,..cVevt..AG % c—c> EMPLOYEE #: DATE: 1....... 2:7 —23 <br />ASSIGNED TO: FrtAA.64.4-ty EMPLOYEE #: DATE: IA .....-2:7 ,..-2_3 <br />Date Service Completed (if already completed): SERVICE CODE: ts- 2,3 i 13 1 E: to N <br />Fee Amount: e‘_‘ --- <br />Amount Paid eii 116. Z ,-- Payment Date /1/(? ''. V <br />/ <br />Payment Type I 6;714--- Invoice # Check # Received By: <br />Digitally signed by NGUYEN NGUYEN <br />APPLICANT'S SIGNATURE: Date: 2023.04.26 1653:39 -0700' DATE: 04/26/2023