Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />51200 gni Z2.S <br />OWNER /OPERATOR <br />� <br />Keith Decker & Dondra Nickell <br />CHECKifBILLING ADDRESS <br />FACILITY NAME Decker / Nickell Property <br />FAX # <br />SITE ADDRESS 4569 <br />E. <br />Harvest Rd. <br />I <br />CITY Lodi <br />Acampo <br />95220 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 3358 <br />E. Acampo Rd. <br />Street Number <br />Street Name <br />CITY Acampo <br />STATE CA Zip <br />95220 <br />PHnuF #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 530) 407-9340 <br />017-020-06 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />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, Standar, jSTATE a FEDERAL 74 <br />APPLICANT'S SIGNATURE. DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANGER ❑ OTHER AUTHORIZED AGENT ❑ <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 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 />SEP 16 2021 <br />S IV JOAQUIN COUIy1 Y <br />HE4LTH EPgRT��LN <br />ACCEPTED BY: 1 [ EMPLOYEE #: DATE: <br />L]% d <br />1.2 7 <br />ASSIGNED TO: EMPLOYEE #: DATE: (�//6 <br />Date Service Completed (if already completed): SERVICE CODE: S 3 P E. <br />Fee Amount: �oY Amount Pai lo�0 DT Payment Date �WZ b <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />