Laserfiche WebLink
SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH11!IIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#ASERVICE REQUEST# <br /> (Loc 4 (,:2q I S <br /> OWNER/OPERATOR Madalena Moules CHECK If BILLING ADDRESS® <br /> FACILITY NAME Moules Property <br /> SITE ADDRESSI o(I.I Nl�1 Jack Tone Road 95240 <br /> 13737 & J4et iYu1 bei IMajon Street Name Lodi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 12951 E. Herne Lane <br /> Street Number Street ama <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 EIu. APN# LAND USE APPLICATION# yO+ <br /> ( 1 063-250-27 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way 12091369-4228 <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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S ndar s,STATE and FEDERAL laws. /' <br /> APPLICANT'S SIGNATIU14 DATE: (O <br /> PROPERTY/BUSINESS OWNER t OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPL/CANT is not the BILLING 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 environmentaVsite 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: Soil Suitability Study & Engineered Septic Design RECEIVED <br /> COMMENTS: / an -717,10t'-717,10t'-717,10t' %'�r� sn ,JUN Q 5 2006 <br /> -"���$ MARONMENTALTM <br /> <ZDita�.1, <br /> e owe HEALTH DEPARTMENT <br /> APPROVED BY: (�L f�, EMPLOYEE#: D&2-f DATE: (o It,N <br /> 6 <br /> ASSIGNEDTO: CS GO"l�?) EMPLOYEE#: S4T4DATE: <br /> Date Service Completed (if already completed: SERVICE CODE: `z 7 PIE: zon11 <br /> Fee Amount: . N Amount Paid 6J Payment Date D b CJ b Ip <br /> Payment Type Invoice# Check# }! Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />