Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'bu <br /> OWNER/OPERATOR <br /> Bill Williams CHECK If BILLING ADDRESS <br /> FACILITY NAME Williams/Felix Property <br /> SITE ADDRESS 5023 E. Ashley Ln. Stockton 95212 <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 8027 W. Howard Rd. <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 594-9126 086-070-22 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION <br /> l LOCATION CODE <br /> ( ) `�— 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,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, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and awhe same time it is <br /> provided to me or my representative. � <br /> ! Y <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study e�`/ <br /> COMMENTS: L� , g '�t7 0 ��" J <br /> NC W �D <br /> EN�gQUI 9 <br /> I�ITyO M�NTuN'Y <br /> gRryENr <br /> ACCEPTED BY: EMPLOYEE#: DATE:S <br /> ASSIGNED TO: j EMPLOYEE#: DATE: A 3 CJ <br /> Date Service Completed (if already completed): SERVICE CODE: �� PIE: Z <br /> Fee Amount: Amount Pai .U� Payment Date S� <br /> Payment Type Invoice# Check# /Do Recei ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />