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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# Bill Dappert SERVICE REQUEST# Hotel I Sq PHONE# En. 570 517-4876 P Amusement FAX# 2500 Daniels Street EMPLOYEE M OWNER / OPERATOR CHECK If BILLING ADDRESS Great Wolf Resorts SERVICECODEI - j5 FACILr�NeafWolf Lodge Manteca California SITEADDRESS 2500 Daniels Street Manteca 95337 Street Number DI ¢aeon SUee Ne a Invoice# 1c06#J Cit II Co e HOME or MAILING ADDRESS (If Different from Site Address) Street Number SetN..e CITY STATE ZIP PHONE#1 Exr. APN # LAND USE APPLICATION # ( 570) 517-4876 241-31-64 PHONE#2 Exr• 1 ) BGS DISTRICT LOCATION CODE CONTRACTOR / SERVICE RE' QUESTOR REQUESTOR CHECK if BILLING ADDRESS Bill Dappert 1 _ J L FjOUYYLNYtr�% 1r e.SF�•�•V�w^-r'1 nn- `�l-�Y ✓ i✓✓L-(TL.��J/ � tan s ti gyp) p 2t� BUSINE SN reat�lolf Lodge ACCEPTED BY: PHONE# En. 570 517-4876 HOME Or MAILING ADDRESS DATE: CK— t-7 -'Z2 FAX# 2500 Daniels Street EMPLOYEE M 1 ) CITY Manteca STATE CA ZIP 95337 BILLING ACKNOWLEDGEMENT: 1, 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 applicatio) and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE If ERAL laws. 7 APPLICANT'S SIGNATURE: / Irr DATE: ti'/C/ 2Z PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER Lp OTHER AUTHORIZED AGENT W e')cl, %1'l rl f"riGP/ !fAPPLICANT/s not the BILLING PARTY proof ✓if`authorization rosign isreriuired Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property foes NYY above site address, hereby authorize the release of any and all resuhs, geotechnical data and/or envh•onmental/site a _ _ _ _ __ _ • .-.ILLI _J _f f4.....a! f...nn . provided to me or my representative. AUG2022 TYPE OF SERVICE REQUESTED: Inspection of Plumbing for Dining Room/Kitchen Modfications +NN JOAQN COMMENTS: 1 _ J L FjOUYYLNYtr�% 1r e.SF�•�•V�w^-r'1 nn- `�l-�Y ✓ i✓✓L-(TL.��J/ � tan s ti gyp) p 2t� ME ��fNLTH NiPAR ACCEPTED BY: [ Sw EMPLOYEE M DATE: CK— t-7 -'Z2 ASSIGNED TO: �� EMPLOYEE M DATE:'q-- (7 r-,)_2_ •i -z - Date Service Completed (If already completed): Date SERVICECODEI - j5 Fee Amount: Amount Paid Payment Date �L Payment Type Invoice# 1c06#J 5`5RecelvedBy: EHO 48-02-026 g l l b� -� LZ- SR FORM (Golden Rod) REVISED 11/17/2003 UNTY AL MENT