Laserfiche WebLink
New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form Be <br />Facility Name <br />Site Address City ZIP <br />APN <br />^^Consultation Jf^Change of Owner Repairs or Remodel Other <br />VIN <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br /> Contractor Architect Facility Owner Facility Contact Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />CA <br /> Contractor Architect Facility 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 Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />DATE: <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br /> Check II Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Phone <br />^>1 O S C?0 3| <br />Application for <br />Operating Permit <br />Payment <br />Received By <br />^Billing Party <br />Type of Service <br />Requested <br />Comments <br />2'7 <br />Supervisor District <br />Record Number <br />100^1 <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 application and that the work tq be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. /B’ / Y / (l/A'A <br />APPLICANT'S SIGNATURE: DATE: <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />2-^> OCMg>So <br />State <br />Assigned Tol<cxd eanne, l <br />^Confirmation It <br />Date PE <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 autB8i¥Cj0 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONfiitly^AljH^LIH <br />DEPARTMENT as soon as ids available and at the same time it is provided to me or my representative. <br />2^7qq 6 ^f <br />I Phone <br />'fb_____,VTXC4t P v t 6>r/y <br />License Plate Number, <br />_____________ <br />Email <br />Skr^ IC ex' vq C -j <br /> Property Owner