WORK PLANS - Laserfiche WebLink

Home Browse Search

^\New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Consultation Change of Owner Repairs or Remodel Other Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license number Phone Billing Party Facility Owner Property Owner Contractor Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email Billing Party Facility Owner Facility Contact Property Owner Contractor First Name Last name Address City State 2H2H Phone Phone Email DATE: Linked FA IDAssigned To •J PE FeeDate Infirmation it Cash Check ti Rev 07/10/2024 W2.VO0OAO If mobile food truck or pumper truck Contact Types required Application for Operating Permit Payment Received By If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. City City VIN 13^^61-10} 0-505 ZIP Q5 33^ ZIP 953^ State Type of Service Requested Comments Record Number ApaLpoaq 50 Vi 5-| Site Address APN AccGpted By y < \ySt^cia lope ______/ L <■ z /'aA _ Facility Contact I State CA Address Phone Last name S< VA License Plate Number _ HTJ 6SC’S Facility Name -|-p Supervisor District r* - J □ Architect If contractor, indi|^^^£d number JAN Sa^J0aqiiii - - BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowredge ©atSU^^jtd/or-projcct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified'on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. . .A • / > /zi z APPLICANT'S SIGNATURE: ( Lt) f S I DATE: / f 5 /O ^PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT _ ^8^ Title