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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> C & T Murphy Partners, /o Chester Murphy <br /> FACILITY NAME <br /> SITE ADDRESS E Oakwood Road FStockton 95215 <br /> 20449 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1506 Countrywood Lane <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Escalon CA 95230 <br /> PHONE#1 EXT• APN#(Portion) LAND USE APPLICATION# <br /> (209 ) 691-6162 185-080-35 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy, C/o Joe Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 2180 ( ) <br /> CITY Lodi STATE CA ZIP 95241 <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 FEll,RAL laws. <br /> APPLICANT'S SIGNATURE: DATE:: /�{ —r I/�j <br /> -7c) <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHORIZED Ac ENT Or Engineer <br /> IfAPPLICANT is not he/ILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS 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 DEPAR'T'MENT as soon as it is available and at theAsame time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A <br /> S1% R D ?® <br /> N FSR QU/N COU <br /> ZQ <br /> �9�TyDFpgR���IY <br /> NT <br /> ACCEPTED BY: 1 x `k0vQ"V`—L' EMPLOYEE#: DATE: �1 r1 /7 <br /> ASSIGNED TO: C 1 10 <br /> A EMPLOYEE#: DATE: `v G <br /> Date Service Completed (If already completed): SERVICE CODE: 6�Z P i 2 <br /> Fee Amount: Amount Pai JOT- O Payment Date li <br /> Payment Type Invoice# Check# 8LNg Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />