Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#,I <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Marco Pacheco <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 11550 E. Norman Avenue Stockton 95215 <br /> Street Number I Direction street Name cit Zi Cotl, <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( 209 ) 662-2741 103-290-28 <br /> PHONE#2 EXT. BOS DISTRICT LOGAT ON CODE <br /> i <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# ERT' <br /> Dillon & Murphy 209 1 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 1 209) 334-0723 <br /> CITY Lodi STATE CA Zip 95241 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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: N DATE: March March 9, 2018 <br /> PROPERTY/BUSINESS OWNER❑ ffBLIN <br /> TOR/MANAGER ❑ OTHd AUTHORIZED AGENT 00 Civil Engineer <br /> !flIPPL/CA1J/'is notG PAerrproofof authoriZatian to sign is required rime <br /> AUTHORIZATION TO RELEAORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby author 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: I <br /> COMMENTS` PAYMENT <br /> / <br /> RECEIVED <br /> DAL MAR 0 9 2018 <br /> ACCEPTED BY: OYEE E.NVI ,�'Ft1NT <br /> r. <br /> ASSIGNED TO: HEMPLOYEE M ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'L P 1 E' <br /> Fee Amount: Amount Paid f3 d L4 Payment Date �9 L <br /> Payment Type V 0Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />