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i <br /> i <br /> i <br /> ❑ New Facility ❑ Existing facility <br /> I <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Mountain House Water Treatment Facility <br /> Site Address <br /> .18045 S. Kelso Road �rMountaln House stag CA ZIP 95391 <br /> I <br /> APN Supervisor District <br /> 258-020-29 Tracy <br /> Type of Serv€ce ❑Application for Cl Cansultat€nn Q Change of Owner G Repairs or Remntlet (Other <br /> Requested operating Permit <br /> Comments Well permit <br /> If mobiles food truth or License Plate Number VlN --- <br /> pumper truck <br /> Contact Types Ci Riil€ng Party ner Q Facility Contact Q Property Owner 0 Contractor 11 Architect <br /> required , <br /> D Illne Party ❑Facility Owner U Facility Contact n Property Owner 0 Contractor ❑Architect <br /> First Name wren Last name Morgan If contractor, Indicate type and license number i <br /> Address City State ZIP <br /> 2100 Goodyear Road Mountain Horse CA 95391 <br /> Phone trhor� Email <br /> (925) 313 56 88 !' , 5�'`t� kmorgan@sjgov.org <br /> Gf Billing Party ❑Faclllty Owner E]Facility Contact C l Property owner 0 Contractor D Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Entail <br /> I <br /> - I <br /> Billing Party Cl Facility Owner U Facility Contact d Property owner Q Contractor fa Architect <br /> I <br /> First Name Last name If contractor,Indicate type and flcense number <br /> Address City State W ZIP <br /> Phone Phone Y I mail j <br /> - i <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 /> L also certify lhal€have prepared this pp'cation and that ffe�iork be performed will be done in accordance sv' h all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards STATI:and FEDEftnLlaws, ! <br /> APPLICANT'SSIGNATURI;: �� `�--_ DATE: <br /> ©PROPERTY/BUSINESS OWNER 14 OPERATOR/MANAGER C€OTHER AUTHORIZEDAGENT Utilities Manager <br /> Title <br /> IF APPLICANT Is not the BILLING PARTY,proof of authorizatlon to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:Whets applicable,1, the owner or operator of the property located at the above site address,hereby authorize the <br /> It-lease of any and all results,geotechnical data anti/or onvlronmenlal/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 PA ID. JL <br /> . ' <br /> Date. Fee : Record Numbs r r <br /> ®:o i <br /> 4 <br /> ❑cash M Check f! Conflrmatt.on It / �( ! Payment ` <br /> . i3Y �� f <br /> 1 <br /> Rev 07/10/2024 l <br /> I <br /> r <br /> i <br />