WORK PLANS - Laserfiche WebLink

Home Browse Search

New Facility Existing Facility San Joaquin County Environmental Health Department Application Form APN Consultation Change of Owner Repairs or Remodel Other License Plate Number VIN Property Owner Contractor Billing Party Facility Owner Facility Contact Architect Billing Party Property Owner Facility Owner Facility Contact Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address 553. Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name State ZIPAddressCity Phone EmailPhone j Property Owner Contractor Architect Facility Contact Billing Party Facility Owner First Name Last name StateCityAddress W^8-0-2O25EmailPhonePhone OTHER AUTHORIZED AGENT Title Linked FA IDAccepted B^ PE I (o 0 \ Confirmation If Check ft Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALIH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Application for Operating Permit Email 1 5- HBfiTQN Phone City STOCkToN Phone If contractor, indicFa^peM EMT11 m bor Type of Service Requested Comments LA KAHCHEF-nA ZIP e. uOft-re^uDO Ro Supervisor District Tog.T7LuE.E.| ft City __________ State ZIP ^5 3 0S~ Facility Name Site Address ’do LX Assigned Vo15 I- Fee S37 Record Number __ _APa-5<2>2^34 Payment Received By ----- 1 -- - SAN JOAQbfN COUNTY— BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ack^W^MWA/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me^hftHjsiW^BARJMENTn this form. 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, Standards, STATE and FEDERAL laws. J . j 1 ~ APPLICANT’S SIGNATURE: DATE: / C? I PROPERTY / BUSINESS OWNER OPERATOR / MANAGER State __C.A Cash