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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FA 000 2,11 i- <br />SERVICE REQUEST # <br />Gc ooio-3g 1 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME River Rock Apartments: Pool 1&2 <br />SITE ADDRESS 504 <br />Street Number Direction <br />Northbank Ct <br />Street Name <br />Stockton <br />City <br />95207 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( I <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS M <br />BUSINESS NAME <br />Burkett's Pool Plastering <br />PHONE # <br />( ) 209-624-2921 <br />Err. <br />HOME or MAILING ADDRESS <br />600 N. Frontage Rd. <br />FAX # <br />( ) <br />CITY Ripon STATE CA ZIP 95366 <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, Standards, ST ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: &/1.0.41, 7YL DATE: 3/27/2019 <br />m <br />PROPERTY / BUSINESS OWNER': OPERATOR / MANAGER El OTHER AUTHORIZED AGENT ual Draftsman <br />tfAPPL/CANT 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 Ail e it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Plan Review 714-1•7 itte,14^-15"defi <br />-.., to efraz <br />Ilfilit) COMMENTS: 2 p <br />8441 JOA U 20'9 Ai 4)Vi4iiQUiN <br />eqtr, 044,,,,,COIJ A, <br />r'l 10E-p4-1,21y7,11:1 I Y <br />rrr4tAir <br />, <br />ACCEPTED BY: EMPLOYEE #: <br />(‘ j 1 3 DATE: - 2,... /I <br />ASSIGNED TO: <br />.--. <br />, / <br />I EMPLOYEE #: (a zi 3 DATE: 7.2) it.. / 1 ti ' Ar <br />Date Service Comp! tel (if already completed): SERVICE CODE: -3 <br />Fee Amount: <br />3() L-1- <br />Amount Paid36 - <br />P 1-tj'clO z„, <br />Payment Date <br />Payment Type I/ '.‹ <br />1 4., <br />Invoice # Check # 7y3e1S-6,2!/- Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003