Laserfiche WebLink
SAN JOAQUPT :OUN, tRONMENT.ILHEALTH DfEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTAllik 8 1 L - - # <br /> 52oo So3a <br /> OWNER/OPERATOOr"I CHE f L <br /> Mr_ <br /> FACILITY NAME <br /> Vrielin Pro ert <br /> SITE ADDRESS 23725 S Frederick Ripon 95366 <br /> Street Number ire 'o S et Na CI L e <br /> HOME Or MAILING ADDRESS (If Different from She Address) 1849 Burgundy Lane <br /> Street Number Street Name <br /> CITY STATE ZIP 95366 <br /> Ripon <br /> PHONE#1 E)ff' APN# LAND USE APPLICATION# <br /> (209) 599-3080 228-130-23 PA-05-157 (MS) <br /> PHONIER BOS DISTRICT LOCATION CODE <br /> ( ) 614-1235 / SERVICE REQUESTOR <br /> REQUESTOR CHECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> HOME or MAILING ADDRESS FAX# <br /> 209 369-4228 I 9nQ I 4 <br /> CITY STATE CA zip <br /> Lod <br /> 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. 1 a <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER[3 PERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT 13 4: g "A�-V— <br /> /fAPPLICANT is not the BILLTNO PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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, l� <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study�/I I ' �• — q yM <br /> COMMENTS: 'Z /p' <br /> 115 DEC/ i zoo S z <br /> VW' ,0, ENVIRONMENT HEALTH y�Vjq�111N�20�s <br /> 1� � ' pyo �.i� � PERMIT/SERVICES �irNOFpgFNT0a7y <br /> APPROVED BY: V E t EMPLOYEE#:0�Z_/ DATE: `� <br /> ASSIGNED TO: v{Eti 17y NE EMPLOYEE#:l/ � C) DATE: / 1/ c <br /> Date Service Completed (if already completed): SERVICE CODE: Ste. q 2 L 1 PIE: lG <br /> Fee Amount: _ /��qD 2 =$37 2- Amount Paid zi� �3-T?00 Payment Date <br /> Payment Type Invoice# Check# C( 31 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />