WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Commercial BUSINESS NAME Spediacci Construction, Inc PHONE# En. 209 954-9282 FACILITY ID # S RVICE REQUEST # OWNER/OPERATOR David Calder CHECK If BILLING ADDRESS FACILITY NAME David's Pizza A SN � �AQUI SITE ADDRESS 4755Quail Street Num bar I Direction Lakes Dr. Street Name Stockton city 95207 Zip Code HOME or MAILING ADDRESS (if Different from Site Address) 1744 SVeet Number W. Hammer Ln. Street Name CITY Stockton DATE: 5-11-21 STATE CA ZIP 95209 PHONE#1 EM ( 209 ) 744-2677 EMPLOYEEM 3361 APN# 112-210-13 Date Service Completed (If already completed): LAND USE APPLICATION# PHONIER Eu. ( ) P I E: 1601 Fee Amount: 456 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dan Spediacci CHECK If BILLING ADDRE BUSINESS NAME Spediacci Construction, Inc PHONE# En. 209 954-9282 HOME or MAILING ADDRESS 4950 Buckley Cove Way, Suite 4 - Stockton, CA 95207 FAx# 1 ( ) CITY Stockton STATE CA ZIP 95207 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: DATE: 5-11-2021 PROPERTY/ BUSINESS OWNER❑ OPERAT /MANAGER❑ OTIHIiia AUTHORIZED AGENT® Architect IfAPPL/CANT is not the BILLING PARTT proof of authorization to sign is required Titre 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 environmentaUsite 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. nA 31 TYPE OF SERVICE REQUESTED: rl r Al ENT COMMENTS: D ?021 A SN � �AQUI HEALTNTY tRD PAR -r ACCEPTED BY: Vidal Pedraza EMPLOYEEM 62.13 DATE: 5-11-21 AsSIGNEDTO: Marlbel F)OhrschntZ EMPLOYEEM 3361 DATE: 5-11-21 Date Service Completed (If already completed): SERVICE CODE: 523 P I E: 1601 Fee Amount: 456 Amount Paid t-fS�, �� Payment Date Payment Type V I Invoice # Check # 1 �� G I R �O Received By: EHD 48-02-025 Payment confirmation # 125191988 REVISED 11/17/2003 SR FORM (Golden Rod)