Laserfiche WebLink
SAINT JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businessor Property FACILITY ID# SERVICE REQUEST# <br /> OVVIVER OPERATOR <br /> ®ctavio Medina CHECKi1 BILLINGADDRESS0 <br /> ' FACILITY NAME <br /> SITE ADDRESS <br /> t 824 S Hinkley Avenue Stockton 95215 <br /> Street Plumber Direction Street ame <br /> Ci Zip,Code <br /> HOME Or MAILING ADDRESS (9t Different ffrDrta Site Address) <br /> 2522 Grand Canal Blvd. #14 <br /> Stree4 Number Street Name <br /> CITY TE ZIP STATE CA 95207 <br /> PHONE#'l EXT. APP.# LAND USE APPLICATION <br /> 1 209)470-9026 157253-13 <br /> ' PHONE#2 SOS DISTRICT <br /> L--( 1 � LOCATION CODE <br /> ' <br /> CONTRACTOR,� SERVICE REQIJ.ESTt1I�REQUESTOre <br /> Joe Murphys CHECK i3'BILLING ADORE <br /> BUSINESS NAMr=' PHONE# Exr.Dillon & Murphy 209 334-6613 317 <br /> HOME Or MAILING ADDRESS FAX# <br /> 847 N. Oluff Avenue, Suite A2 Q209 ) 334-0723 <br /> ' CITlt Lodi STATE CA 7JP 95240 <br /> BILLING AGEMENT: 1, the undersigned property or business owner, operator or authorized agent ®f sa e, <br /> acknowledge that all site and/or project specific ENviRoNMENTAL HEALTH DEPT.RT,,SNT 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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQ'U[N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laves. <br /> ' APPLICANT'S SIGNATUI E\\�/r✓ � �/� DATE: <br /> PROPERTv/Bus3NESs OWNER® PERATOR/MANAGER ® OTHER AUTHORIZED AGENT gEngineer <br /> If APPLICANT is not e ILLINGPA: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, geotechnicai data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTWSNT 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: � � � �� PAYMENT <br /> ' COMMENTS: <br /> AUG 2 3 2018 <br /> ' 8AN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT' <br /> AeGGEPTED BY: EMPLOYEE#: DATE: g !ASSIGNED TO: <br /> EMPLOYEE <br /> Date Ser4ce Completed already completed), SERVICE CODE: P I E: <br /> 5 3 �(�03 <br /> ' Fee Arraouri : �O Am <br /> cunt Pai 30�6D Payment Date ho <br /> Hy`men=tType �/L 1nv®ice# Oheek# I S��—b Recefved By: ^ <br /> ' END SR FORM(Golden Rod) <br /> REVISEDSED 9 1111 91'17!2003 <br /> i <br />