Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRO IFALTHDEPARTMENT <br /> SERVICE VEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Lucia Grillo CHECK If BILLING ADDRESS <br /> FACILITY NAME Grillo / Podesta Property <br /> SITE ADDRESS 11418E. Comstock & 6655 N. Beecher Stockton 95215 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7198 N. Tully Rd. <br /> Street Number Street Name <br /> CITY Linden STATE CA Zip 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 931-1366 089-130-28 & -57 pAr I Ir6oaZ Z <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA Z'P 95240 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT P C D Nd U L-77?'T <br /> IfAPPL/CANT 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: Review Soil Suitability Study RECEDIED <br /> COMMENTS: <br /> NOV 2 8 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> /,� HEALTH DEPARTMENT <br /> Z3 l (®U <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r P I E: <br /> Fee Amount: v Amount Paid 3 p Payment Date <br /> Payment Type \ Invoice# Check# Ste, �� ? Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />