Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACILITY IDK SERVICE REQUEST# <br /> OWNER 10 P ERATO R BILLING PARTY 0 <br /> Daniel Lowry c/o D •ede Construction <br /> FACILITY NAME <br /> SA-01-4 Aspire School <br /> SUE ADDRESS <br /> 11492 N&r.th Highway 99 East Frontage Road <br /> Strttt Numbw 'tenon Strtet Name Type SVN1I <br /> Mailing Address (If Different from Site Address) <br /> P .O. Box 1007 <br /> Crrr Woodbridge STATE CA ZIP 95258 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE 442 EXT. BOS DISTRICT LOCAT)ON CCOE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY 0 <br /> Cecil Dillon <br /> BUSINESS NAM PHONE# T• <br /> illon & Murphy P09) 334-6613 <br /> MAILING ADDRESS FAX# <br /> _ P .O. Box 2180 ( 334-0723 <br /> CrTY Lodi STATE CA "P 95241 <br /> I <br /> BILLING ACKNOWLEDGEMENT: I• the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or actNity will be bill to me or my business as identified on LiIs form. <br /> I also certify that I have prepared this appligtion and that the work to be performed will be done in accordance with all SAN JOACUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. w <br /> }� APPLICANT SIGNATURE: , i Cecil Dillon DATE: 4/20/01 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0711ERAUTHORZEDAGENT 0 Engineer <br /> ifAcvucwr is riot Me R1 reC Purry proof of authoeiratlon to sign is requirod Ti tlo <br /> 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 <br /> any and all results,geotechnical data and/or environmentaftte assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> �.GirIh1EN7S: <br /> This fee is to review the Soil Suitability/Nitrate Loading Study <br /> for SA-01-4 . If you need additional information please contact <br /> Cecil Dillon at (209) 334-6613 . <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: DATE: �� <br /> ASSIGNED T0: f Cl ;ry Cd EMPLOYEE#: �1/ C Lf L DATE: <br /> Date Service Completed (if already completed): ` SERVICE CODE: 7 S' .PIE: 24P 0 Z <br /> FeeAmount: y_� 5 Amount Paid `l 3 s b C Payment Date <br /> ayment Type Invoice#' Check 9C eceive By: <br />