WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME Wilkus Architects SERVICE REQUEST # Food service - delivery/take out HOME or MAILING ADDRESS 15 Ninth Ave. N Seot) 7V�2- OWNER / OPERATOR STATE MN ZIP 55343 Ranjan Bhasin CHECK if BILLING ADDRESS❑ FACILITY NAME Wingstop EMPLOYEE#: 6213 SITE ADDRESS 1687 N California Street DATE: 2_7_22 Stockton 95204 Street Number 1'.0 Streeta Amount Pai city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1063 Invoice # Cheshire Circle Street Number Street Name CITY Danville STATE CA ZIP 94506 PHONE #1 EIR. APN # LAND USE APPLICATION # 1 925) 260-3605 PHONE #2 EZ . BOB DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Kirk Thunberg CHECK If BILLING ADDRESS BUSINESS NAME Wilkus Architects PH E Exi. �� 592-5085 HOME or MAILING ADDRESS 15 Ninth Ave. N FAX# ( ) CITY Hopkins STATE MN ZIP 55343 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, Standar , ST TE ddd FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 02/03/2022 PROPERTY/BUSINESS OWNER OPE R/MANAGER❑ OTHER AUTHORIZED AGENT® Architect/Designer If APPLICANT is not the BILLING PARTY proof of authorization 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 andjqthe same time it is provided to me or my representative. r A YnRn TYPE OF SERVICE REQUESTED: Food service plan review CFS COMMENTS: (77 SgN�o OO 2022 HEq THDjA47-RTM�Nry ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 2_7_22 ASSIGNED TO: Darla Afonskaia EMPLOYEEM 9825 DATE: 2_7_22 Date Service Completed (If already completed): SERVICE CODE: 523 P I E: 1601 Fee Amount: 456 Amount Pai 56 b Payment Date zZ_ Payment Type Invoice # Check # 0 Received By: EHD 48-02-025 Payment confirmation # 138551043 SR FORM (Golden Rod) REVISED 11/17/2003