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❑ New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> White Slough Water Pollution Control Facility <br /> Site Address City State ZIP <br /> 12751 N.Thornton Road Lodi CA 95242 <br /> APN Supervisor District <br /> 05513016 District 4 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel IO Other <br /> Requested Operating Permit <br /> Comments <br /> Monitoring Well Destructions and Construction <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck N/A N/A <br /> Contact Types I]Billing Party [I Facility Owner ❑Facility Contact [I Property Owner ❑Contractor ❑Architect <br /> required <br /> II]Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Charles Hardy West Yost Associates <br /> Address City State ZIP <br /> 1001 Galaxy Way, Suite 310 Concord CA 94520 <br /> Phone Phone Email <br /> (925)949-5814 N/A chardy@westyost.col <br /> ❑Billing Party IO Facility Owner ❑Facility Contact IO Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> City of Lodi N/A N/A <br /> Address City State ZIP <br /> 12751 N.Thornton Road Lodi CA 95242 <br /> Phone Phone Email <br /> (209)333-6749 (209)333-6832 kcapitanich@lodi.gov <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner IO Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Ralph McGahey C-57 Contractor License#1035255 <br /> Address City State ZIP <br /> 6821 8th St. (Confluence Technical Services, Inc) Rio Linda CA 95673 <br /> Phone Phone Email <br /> (916)760-7641 N/A rmcgahey@conflu ncetechnical.com <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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 1/14/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 17 OTHER AUTHORIZED AGENT Engineering Consultant <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 /> Date PE Fee Record Number <br /> ❑ Payment Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />