Laserfiche WebLink
New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />0 FX <br />Site Address State ZIP <br /><e>Vv < ft <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Owner Property Owner Contractor Billing Party Facility Contact Architect <br />If contractor, indicate type and license numberFirst Name <br />Address City State ZIPCA ^5 MB <br />EmailPhone <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />PhonePhone Email <br /> Property Owner Contractor Facility Owner Facility Contact Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />linked FA IDAccepted By <br />Fee <br />^01 4 <br /> Check It <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 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 /> Application for <br />Operating Permit <br />Application Form <br />l/G < I ___________ <br />Type of Service <br />Requested <br />Comments <br />s C^\\ <br />Supervisor District <br />ex. Z' vv C <br />PE <br />License Plate Number <br /> Billing Party <br />, * Payment i <br />Received By <br />. I Architect <br />___ <br />Sa^joaq <br />’ r <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknWtWiPfi^^l^eSnd/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as itWfflfled on this <br />form. . <br />I also certify that I have prepared this application ajxrthat lie work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. f J j y „ <br />APPLICANT'S SIGNATURE: DATE: ' <br />OPERATOR / MANAGER <br />ZIP <br />'2025 <br />VINi Fc -f i=^ lss:3» ( <br />Last name t <br />5 |o -35A-«n«ih Phone <br />Assigned To _______ <br /> Confirmation « <br />Date <br />cl <br />'' Cash