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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Pacheco Property <br /> Site Address City State ZIP <br /> 172 N. Patton Ave. Stockton CA 95215 <br /> APN Supervis District <br /> 103-100-34 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Il Other <br /> Requested Operating Permit <br /> Comments <br /> Review Soil Suitability/Nitrate Loading Study <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> DQ Billing Party ❑Facility Owner ❑Facility Contact M Property Owner ❑Contractor ❑Architect <br /> First Name Marco Pacheco Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 11550 Norman Ave. Stockton CA 95215 <br /> Phone Phone Email <br /> (209)662-2741 pacheco032@yahoo com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Abby Racco Live Oak GeoEnvironmental, CEG 2151 <br /> Address City State ZIP <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209) 369-0375 liveoak.enviro@gma I.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Ctt6EIV ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> AI- R <br /> Address City State ZIP <br /> AN JOAQUIN COU <br /> Phone Phone Email ENTAL <br /> EALTH DEPARTRIIE T <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 applicatiq�haitlie work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. I1i 1 ) <br /> APPLICANT'S SIGNATURE: l,'c' l\ I DATE: n0/ /J ZCO <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENT Lh,7/ <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> NR <br /> Date PE Fee Record Number <br /> �11 <br /> ❑Cash ❑Check# Confirmation# Payment <br /> 2 ! C Received By <br /> Rev 07/10/2024 <br />