Laserfiche WebLink
SAN JOAQU. 20UNTY ENVIRONMENTAL HEALTH ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> "REQUEST# <br /> Retail Drug Store S tLno &- /5-41 L, <br /> OWNER/OPERATOR F and Laurel Partners, LLC(developer for Walgreens facility)CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Walgreens #09723 <br /> SITE ADDRESS NEC Hammer Lane and Kelley Drive Stockton <br /> Street Number I Direction Street Name I City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4 921 Concordia Drive <br /> Street Number Street Name <br /> CITY E1 Dorado Hills SCAZIP <br /> ATE 95762 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 916) 705-1419 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Architect <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Jerold L. Dougal, Architect jldarch@surewest.net PHONE# EXT. <br /> 916 783-8540 <br /> HOME or MAILING ADDRESS FAX# <br /> 1309 Retreat Way ( ) <br /> CITY Roseville STATE CA ZIP 95747 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Stand s, TATE a FEDERAL laws. <br /> Agent's <br /> --A-7'a •r:i�AINT'S SIGNAT DATE: <br /> PROPERTY/BUSINESS OWNER O TOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. F000 L.¢-,J <br /> TYPE OF SERVICE REQUESTED: Plan check for a building permit <br /> COMMENTS: r`� <br /> EN^l�oEe <br /> ACCEPTED BY: 0c—1 L E✓� EMPLOYEE#: 0-32-1 DATE: !/ 30 <br /> ASSIGNED TO: EMPLOYEE EMPLOYEE#: l DATE: W/34/0 <br /> Date Service Completed (if already completed): SERVICE CODE: 5z3 P I : /00/ <br /> Fee Amount: 3(,6 � Amount Paid f3(o p 7 Payment Date 111 3D 1-0 <br /> Payment Type Invoice# Check# L�.S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />