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SAN JOAQUI. ' OUNTY ENVIRONMENTAL HEALIClr'li I��il 'I°I`Vi[�L+ I`�17I9 SERVICE REQUEST Type of Business or Property FACILITY ID # SERV R , e1RtQ # OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ C & T Murphy Partners c/o Chester Murphy FACILITY NAME SITE ADDRESS E Oakwood Road Stockton 95215 WEE 20449 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS ( If Different from Site Address) 1506 Countrywood Lane Street Number Street Name CITY STATE ZIP Escalon CA 95230 PHONE #1 EXT. APN # ( Portion ) LAND USE APPLICATION # ( 209 ) 691 -6162 185mwiNM5 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joe Murphy CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. Dillon & Mur h c/o Joe Murphy 209 334 -6613 HOME or MAILING ADDRESS FAX # P . O . Box 2180 ( ) CITY Lodi STATE CA ZIP 95241 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, Standards, STATE and FED RAL laws . ' - APPLICANT ' S SIGNATURE : DATE : / �( ( � � " PROPERTY / BUSINESS OWNER O ERATOR / MANAGER ❑ OTHER AUTHORIZE, DAGENTLJ Engineer IfAPPLICANT is not he LLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEAS 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 : �, j �� LCA' COMMENTS : 4 swdoq ® 2®20 C% 010 IDA NT ACCEPTED BY : EMPLOYEE # : DATE : j ASSIGNED TO : ( � EMPLOYEE # : DATE . Date Service Completed ( if already completed ) . SERVICE CODE : s-Z �j ` 13150 F. O Fee Amount . i Amount Pai N 1 77 � Payment Date Payment Type /4 Invoice # Check # 83�-g Received By : EHD 4 &02-025 SR FORM (Golden Rod) REVISED 11 / 17/2003