Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IMPARTMENT <br /> SERVICE REQUEST PLEASE EXPEDITE PLAN CHECK <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sandwich Shop <br /> OWNER/OPERATOR <br /> ISP2 Stockton,Inc. CHECK If BILLING ADDRES <br /> FA ILITY NAME <br /> Ike's Love &Sandwiches <br /> SITE ADDRESS <br /> 5308 Pacific Ave#11C Stockton, A 95 a C <br /> Street Number Direction Street Name C Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1210 S. Bascom Ave. Suite 210 <br /> Street Number Street Name <br /> CI STATE Jose CTAATE ZIP 95128 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 831 > 917-6844 <br /> PHONER EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Heidi Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Acute Consulting,Inc. 925 818-4132 <br /> HOME or MAILING ADDRESS FAX# <br /> 29 Orinda Way#1267 ( ) <br /> CITY Orinda STATE zip 94563 <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,Standards,ST n FE AL wS. <br /> APPLICANTS SIGNAURE 7 DATE: 12-19-18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1rr11 Consultant for Business Owner <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. <br /> TYPE OF SERVICE REQUESTED: Interior TI Plan Check for Domino's Pizza Restaurant and adjacent unused space. <br /> COMMENTS: PAYMENT <br /> �x�e-d�� ���� •_ <br /> RECEIVED <br /> c� r 6t CIA4 e — 60n-50 I4�n� r�c„�-' ex��1.0 2 6 2018 <br /> ACCEPTED BY: `-aV Y K�C ! EMPLOYEE#: 114 <br /> DABI4�/I N <br /> ASSIGNED TO: U Y lV JI V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 1 _3SERVICE CODE: Z- 1 PIE <br /> Fee Amount: 4P Amount Paid log q- Payment Date <br /> Payment Type C�rtA, Ccw Invoice# Check# Received By: <br /> EHD 48-02-025 X640 3 J I (, 9 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />