Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Winery �j I <br /> OWNER/OPERATOR <br /> Jeremy Trettevik Cl—V V\f d —1N C CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Jemery Winery <br /> SITE ADDRESS 12080 E ACAMPO ROAD <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6 W. Pine St, <br /> Street Number Street Name <br /> CITY Lodi,CA 95240 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION It <br /> ( ) 209.210.2501 017-270-12 b=BP 1906118-19 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jeremy Trettevik CHECK if BILLING ADDRES <br /> 171 <br /> BUSINESS NAMEPHONE# EXT. <br /> Jeremy Winery 209.210.2501 <br /> HOME or MAILING ADDRESS FAX# <br /> 6 W. Pine St, Lodi,CA 95240 ( ) <br /> CITY Lodi STATE CA Zip 95240 <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 applicatI nd that th5owork to b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard ATE,an EDER , aws. <br /> APPLICANT'S SIGNATDATE: <br /> PROPERTY/BUSINESS OWNER OPE Oklf MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the B/ LING 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 available and@the same time it is <br /> provided to me or my representative. I PAs <br /> �'` <br /> TYPE OF SERVICE REQUESTED: L 1� C� �f�9 �� I�,'� Check 4,# <br /> COMMENTS: UUr / <br /> Plan Check for Engineered Septic System ` JOqQl <br /> (J <br /> HFACTy�FpM'T 4 tN7-y <br /> �'FNT <br /> ACCEPTED BY: �^�a7��� EMPLOYEE M DATE: I�/J3/�Dc� <br /> ASSIGNED TO: �T, _/ EMPLOYEE#: DATE: /J /3 <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P/E: <br /> Fee Amount: 3p'1 Amount P ' 364&Z> Payment Date <br /> Payment Type Invoice# Check# SS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />