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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 9128 S. Priest City State ZIP <br /> French Camp CA 95231 <br /> APN Supesor District <br /> 193-Z2o-71 ry qq <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner X Repairs or Remodel XOther <br /> Requested Operating Permit <br /> Comments <br /> Soil Suitability and Nitrate Loading <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types El Billing Party ❑Facility Owner ❑Facility Contact Property Owner ❑Contractor t-WAruuted <br /> required Designer <br /> filling Party ❑Facility Owner ❑Facility Contact Property Owner ❑Contractor ❑Architect <br /> Firsoame Last name if contractor,indicate type and license number <br /> Sand Serina Lee <br /> Address City State ZIP <br /> 9024 S. Priest French Camp CA 952:31 <br /> Phone Phone Em <br /> 209) 456-6318 Iseriiiina.lee@corn ast.net <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner C ContractorchitGct <br /> Vesigner <br /> First Name Last name If contractor,indicate type and license number <br /> Trudie Winters <br /> Address City State ZIP <br /> 4763 Main Street Oakley CA 94561 <br /> Phone Phone Email <br /> 209 639-1189 --Twinters.trudie@ mail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 2�Vy>;ect <br /> First Name tast name If contractor,indicate type `prlumber <br /> 0,0,- LI <br /> Address City State 8.4 JV P 2025 <br /> ✓Q <br /> Phone Phone Email ��T RSly <br /> H CSV <br /> HO N HAY <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all si /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 to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL lawn <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 /> Accepted By Assigned To Linked FA ID <br /> r�E{,yk S�r�bnn <br /> Date PE Fee Record Num r <br /> Payment <br /> 0 Cash Check# ❑Confirmation# Received By <br />