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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> 262 N. Hewitt Road Linden California 95236 <br /> APN Superv' or District <br /> 093-030-47 Y <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit <br /> Comments <br /> Nitrate Loading Study and Soil Suitability Report <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Co Types�❑Billing Party l ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> regntact uired J <br /> ❑Billing Party 1-5-Facility Owner ❑Facility Contact�--7 0 Property Owner ❑Contractor Cl Architect <br /> First Name Last name If contractor,indicate type and license number <br /> The Mark Diemusch and Elizabeth Lynch Trust <br /> Address City State ZIP <br /> 262 N. Hewitt Road Linden California 95236 <br /> Phone Phone Email <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor CI Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Joe Murphy <br /> Address City State ZIP <br /> P.O. Box 2180 Lodi California 95241 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor CI Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:1,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 a Iicailo and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. L_hj-'2C,Zv <br /> APPLICANT's SIGNATURE: (((���� DATE: _ <br /> ❑PROPERTY,'BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGEN1 Representative PAYMENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title RECEIVED <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site a dr�as7c er b }}{{r�� r ze thy <br /> release of any and all results,geotechnical data and/or environmental/site assessment information o the SAN JOAQUIN COUNTY EI�RmIJ E TA HPALTH' <br /> DEPARTMENT as soon as it is available and at the same time it is provided tome or my representative. <br /> SAN I N col <br /> Accepted By /p�,w Assigned To l- Linked FA ID ENVI_� <br /> ti car` 7`�"�O► <br /> Date / PE Fee Record Number <br /> Ys L Z6vZ -'7Cb•ao <br /> ❑Cash OCheck# ❑Confi Payment <br /> rmation# Received By <br /> Rev 07/10/2024 +V <br />