Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9-6 <br /> OWNER/OPERATOR <br /> Kenneth Hubbard CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 12448 E. Harney Ln. Lodi 95240 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESSIf Different from Site d ess <br /> ( c� eo)rge Davis, 1720 S. Hutchins St. Apt. 25 <br /> SVeet Number Str et Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (650) 279-3893 063-240-25 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 95240 <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,Standa s, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: .-1 DATE: ` 2 w <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL/NG 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/ Nitrate Loading Study <br /> COMMENTS: <br /> APR 2 3 2021 <br /> SAN JOAQUIN COUNT`( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE.Y" `-�'� 2 C' <br /> ASSIGNED TO: C� n EMPLOYEE#: ��� DATE: -(-/•7 <br /> Date Service Completed (if already completed): SERVICE CODE 2�� A P 1 E: 2 <br /> Fee Amount: 0 Amount Paid 1 41Q — Payment Date �2v <br /> Payment TypeInvoice# C ck# � � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />