Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential :L Z(z ' (ALA <br /> OWNER/OPERATOR <br /> JR and DK Investments LLC, C/O Janet Ramirez CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> N/A <br /> SITE ADDRESS Mourfield Avenue Stockton <br /> 3510 95206 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4152 Feather River Road, Ste C <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (209 ) 598-1502 1175-150-51 <br /> PHONE#L ExT• BOS DISTRICT I LOCATION CODE <br /> ( 209 ) 472-0389 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESSO <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon&Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( 209-334-0723 <br /> CITY Lodi STATE CA ZIP 95241 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> APPLICANT'S SIGNATURE: DATE: / � Z O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 8--�1�1 <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 at�tl}e same time it is <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: S 4,f foce c,nc- SO�b o(-CGcE Coni�r" n�tlo>7 �?eporl Re v,eti✓ ' eo <br /> COMMENTS: <br /> SAN,,O R 2010 <br /> � � <br /> HEgNVIR ONAR CUNTy <br /> LTH NTA <br /> ►ENT <br /> ACCEPTED BY: ---T� EMPLOYEE#: DATE: y ZoZ O <br /> ASSIGNEDTO: N�s�f?� EMPLOYEE#: DATE: L1// 7oZO <br /> Date Service Completed (if already Completed): SERVICECODE: 5a3 P 1 E: ��03 <br /> Fee Amount: 430q I <br /> Amount Pai 3 -DZ) Payment Date <br /> Payment Type / Invoice# Check# S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />