SR0084372_SSNL - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Residential R-R FACILITY ID# SERVICE REQUEST# CO�6 ty, OWNER/OPERATOR (/� Paul Armanino CHECK if BILLING ADDRESS® FACILITY NAME SITE ADDRESS 476 North Patton Avenue Stockton �95215Street Number Direction Street NameHOME Or MAILING ADDRESS (If Different from Site Address) cl Street Number Street Name CITY STATE Zip PHONE#t ET• APN# LAND USE APPLICATION# ( ) 103-130+S PHONE#2 , (. ) BOS DISTRICT + LOCATION CODE i9 REQUESTOR CONTRACTOR/ SERVICE REQUESTOR Tonya Scheftner CHECK if BILLING ADDRESS BUSINESS NAME Petralogix Engineering, Inc. PHONE# Exr. HOME or MAILING ADDRESS 209 770-0731 Fax# 26675 Bruella Road Cin Galt ( ) STATE CA Zip 95632 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. --------- APPLICANT'S SIGNATURE: ( J DATE: October 17,2021 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Geologist If APPLICANT is not the BLLLLNGP,4,R proofofauthorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENvIRoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Nitrate Loading/Soil Suitability Study Review PAYMENT COMMENTS: q Submitting on behalf of client property owner. i<e,e Ivef.?I U��" N i��"I �`� ��t7��I' nCT 19 2021 aAN JOAQUIN COUNTY, ENVIRONMENTAL' HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: M < EMPLOYEE#: DATE: )JI��lb/ Date Service Completed (if already completed): SERVICE CODE: P E, �,Cloi Fee Amount: `j L r) Amount Paid 6 Z) / q ' Payment Date l 0 G L Payment Type V G S [�— Invoice# C # 13 3 3 Received By: EHD 025 REVISEDSED 11117/2003 SR FORM(Golden Rod)