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® New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 11065 N. Alpine Rd. ADU <br /> Site Address City State ZIP <br /> 11065 N. ALPINE RD. STOCKTON CA 95212 <br /> APN Supervisor District <br /> 063-040-230-000 '//99 9 <br /> Type of Service ❑Application for B Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Request for Review of Soil Suitability Study/Nitrate Loading Study(SSNLS)uploaded 7/8/26 for removal of hold for Permit RES-DWELLING-BP-2504562 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact 9Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Add ess City State ZIP <br /> Phone Phone Email <br /> april4484@gmail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type an <br /> Address City State ZIP ED <br /> Phone Phone Email SA <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> DEp <br /> First Name Last name If contractor,indicate type and license n <br /> Address City State ZIP <br /> Phone Phone Email <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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la 7/13/26 <br /> APPLICANT'S SIGNATURE: ATE: <br /> E/PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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 /> 6 <br /> Date 7 2(v PE �o V 7 v Fee ' Cc R rd Number �l <br /> ❑Cash t ❑(CCh`ecck# Confirmation# c `7^I/Yw Payment <br /> 0-T -7 Received By <br /> Rev 07/10/2024 5s tj <br /> Q o(i►.i e� --�j iwt 2 L a 114sc ---p rj s'A/Cis (,if ryf-5 —> 2i0-z* <br />