SU0004612 - Laserfiche WebLink

Home Browse Search

SAN JOA(.–,a,r„JUNTV ENVIRONMENTAL HEALTn.w, .o'ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Sac) C( C'-� z OWNER/OPERATOR Stacey Griffith CHECK if BILLING ADDRESS FACILITY NAME Griffith Property SITE ADDRESS 9422 E. Jahant Rd. Acampo 95220 Street Number Direction Street Name I Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 11875 E. Ma eRd. m Street Number S[ree Name CITY Acampo STATE CA ZIP 95220 PHONE#1 En. APN# LAND USE APPLICATION# ( 209) 365-1758 007-340-09 PA-04-251 PHONE R E;(T. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR David Welch CHECK If BILLING ADDRESS® BUSINESS NAME PHONE# EXT. Neil O. Anderson & Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAX# 902 Industrial Way (209)369-4228 city Lodi STATE CA z'P 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standar T TE and FEDERAL laws. APPLICANT'S SIGNATURE: �pI DATE: _ _©C I PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER yy OTHER AUTHORIZED AGEN lfAPPLICANT is not the BILLING PARTY proof of authorization to sign is require Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: U ," COMMENTS: Please review th attached septic system design. It is applicable to P@4ZXX76 &11. �� DEC 2 0 2004 SAN JOAQUIN COUNTY ENVIIROOpNpMENTAL APPROVED BY: EMPLOYEE#: HEAL 'IMATEAHTMh : ASSIGNED TO: EMPLOYEE#: DATE: Date Service Co eted (H already completed): SERVICE CODE: -Z� PIE: O Fee Amount: Amount Paid ! a ©C) Payment Date to m Payment Type Invoice# Check# — Received y: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02