Laserfiche WebLink
PAIGE WOODWARD <br />Faquty Name <br />Site Address <br />Din <br /> Sheet Number <br />City State <br />Land Use Application # <br />BOS District <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext <br />Business Name <br />Home or Mailing ADDRESS <br />) <br />ZipStateCITY’ <br />*ormed will be done in accordance with all SAN JOAQUIN <br />03/22/2024APPLICANT’S SIGNATURE: X <br />Comments:plan review <br />Date: <br />Accepted By: <br />523 <br />1 <br />SR FORM (Golden Rod) <br />Employee#: 6213 <br />9818 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SERVICE REQUEST # <br /> /W400430 <br />Employee #: <br />|SHWicECooe: <br />I Location Code <br />Type of Business or Property <br />COFFEE SHOP <br />Owner / Operator <br />San Joaquin County Environmental Health department <br /> SERVICE REQUEST <br />I FACILITY ID# <br />Check if Billing Address [4I <br />Fee Amount 486 <br />Payment Type | <br />Payment 181842394 <br />Street Name <br />Zip <br />Payment Date <br />POPPY COFFEE <br />"2001 [ <br />Street Number | <br />Home or Mailing Address (if Different from site Address) <br />Phone# <br />J____L <br />Fax# <br />( <br />APN# <br />11336404 <br />Check if Billing Address D <br />PACIFIC AVE <br />___________________Street Nan <br />Date: <br />T P/E: <br />572^24- <br />Received By. ( <br />STOCKTON, CA I 95204 <br />__________City _________| Z'P Code, <br />Vidal Pedraza <br />Assigned to: Lydia Baker <br />Date Service Completed (if already completed): ______ <br />I Amount Paid^> DO <br />Invoice # Check # <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 pofc----- ----------------- <br />COUNTY Ordinance Codes, Standards^STATCand Federal laws.* // <br />Date: <br />Property / Business OwNEitLd^ Operator / Manager H Other Authorized Agent <br />If APPLICANT is not the RiijjNG PARTY, proof of authorization to sign is required Tin e <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 same time it is <br />provided to me or my representative._________________________________ <br />TYPE OF SERVICE REQUESTED:_________________________/ <br />SA^o. <br />5-28-24 <br />5-28-24 <br />T60T <br />Phone #1 ext. <br />( >(209)815-7952 <br />Phone #2 ext. <br />( )