SU0004638 - Laserfiche WebLink

Home Browse Search

SAN JOAQU%,.LOUNTY ENVIRONMENTAL HEALTH,,..ePARTMIENT SERVICE REQUEST Type of Business or Property FACILITY la# SERV�Of7 REQUEST# OWNER 1 OPERATOR CHECK if BELLING ADDRESS® Mr- Jim Clare FACtLITY NAME Clare Pro ert SITE ADDRESS 8372 S Jack Tone Road Stockton 95215 Street Number Qirection Street Name C ity Zip Code HOME Or MAILING ADDRESS (if Different from Site Address) P.O. Box 31330 Street Number Street Name CITY STATE ZIP Stockton CA 95213 PHONE#t ExT. APN 1�3 � � - Cu5' LAND USE APPLICATION# I 1 O 4g A5 PA-04-519 PHONE#2 EXT. BOS DISTRICT LOCATION CODE { i r CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Ne*1 0. Anderson and Associates Inr- ( 209)367-3701 HOME Or MAILING ADDRESS FAX# 02 Industrial Way (209)369-4228 CITY 1 06 STATE CA ZIP 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: 7 ~ PROPERTY J BUSINESS OWNER❑ O TORI MANAGER ❑ OTHER AUTHORIZED AGENT Qnsultant IfAPPL1CANT is not the BILLING P,4RTY,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 and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Engineered Septic System Design Review COMMENTS: Please review the following Engineered Se is System Design. If you have a WMID please call. �t/ S I �tN.r �111,, ,,, ,�,, zoa5 V SAID JOA UIN COUNTY APPROVED BY: &L t tor EMPLOYEE.#: 3 DA{ �I TMENT ASSIGNED TO: EMPLOYEE#: _5-q%f DATE: Lf Date Service Completed (if already completed): SERVICE COOE:,g'Z Z P 1 E: u� Fee Amount: _ �,(r V Amount Paid Payment Date y Payment Type Invoice# check# Received By: Y1 ;-40ax- EHD 48-01-025 `/ I V SERVICE REQUEST FORM REVISED 6-5-02 �� /t�(!t@� ��, Jb