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• ❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Site Address City State ZIP 20633 Elliot Road Lockeford CA 95237 APN Supervisor District 05121073 Type of Service ❑Application for ,Consultation ElChange of Owner ❑Repairs or Remodel �ier Requested Operating Permit [[ Comments Site Mitigation Well & Boring Permit Application If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required ❑Billing Party ❑Facility Owner ❑Facility Contact LX Property Owner ❑Contractor ❑Architect Crossroads Real E tate LLC First Name Last name If contractor,indicate type and license number Hayden Webster Address City State ZI P 12686 Curry Avenue Lodi CA 95240 Phone Phone Email 209-200-9278 hbwester mails m Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect Partner En ineeri & Science, Inc. First Name Last name If contractor,indicate type and license number Michel Helou Address City State ZIP 490 43rd Street Oakland CA 94609 Phone Phone Email 774-414-3666 mhelou@partneres.com ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on 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.1411lam/�ll- APPLICANT'S SIGNATURE: DATE: 3/3/2026 ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER QQ OTHER AUTHORIZED AGENT Project Manager Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To c Linked FA ID Date. PE Fee cl Record Number t Z.�1 5 3 Co19 a2.2, ElCash ElCheck# P Confirmation# L( L7 Payment Received By Rev 07/10/2024