Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR <br /> Sergio Martinez CHECK If BILLING ADDRESS <br /> FACILITY" <br /> SITE ADDRESS 135 N Olive Avenue Stockton 95215 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 24242 Partridge Lane <br /> Street Number Street Name <br /> CITY Acarrlpo STATE CA z'P 95220 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 481-5872 157-210-28 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dillon & Murphy, c/o Cesar Palacios CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy ( 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box \ (209)334-0723 <br /> CITE' Lodi STATE CA z'P 95241-2180 <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 FEDERf�L laws. <br /> APPLICANT'S SIGNATURE: � �,.4 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Staff <br /> If APPLICANT 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availal��nd.,3ithe same time it is <br /> provided to me or my representative. '��7/�M�N <br /> r <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: SAN ' 2019 <br /> JOAQU! IJ <br /> !! elml? N N CDUN <br /> �ALTH pE 'riw�N�?' <br /> ACCEPTED BY: ✓ EMPLOYEE MATE: <br /> > I <br /> ASSIGNED TO: EMPLOYEE#: DATE: G' <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: <br /> Fee Amount: C Amount Paid Payment Date 'a~ " <br /> Payment Type Invoice# Check# �� 4� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 #1926 <br />