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SAN JOAQL7.'?C000UNTV ENVIRONMENTAL HEALTHViPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SppER��VICE REQUEST# <br /> f'f/!l <br /> OWNER/OPERATOR Robert Edelman <br /> CHECK N BILLING ADDRESS <br /> FACILITY NAME Whiskey Slough Marina ,,,.✓ <br /> SITE ADDRESS 3401 s Whiskey Slough Road Stockton crndo <br /> Sheet Number tion I SV.etN..e Ci <br /> HOME or MAILING ADDRESS (If Different from She Address) 18 Crow Landing Court <br /> Street Number Street Name <br /> CITY San Ramon STATE CA ZIP 94583 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# l <br /> ( ) 131-080-13 PA-06-320 r�c� <br /> PHONE#2 Eir. BOS DISTRICT LOCATION CODE V <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR v1 <br /> REQUESTOR Nancy R. Kramer CHECK If BILLING ADDRESS® <br /> la <br /> BUSINESS NAME PHONE# Exr' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 , n <br /> HOME or MAILING ADDRESS FAX# v\ <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _� DATE: -Z. — <br /> PROPERTY/BUSINESS OW NER❑ OPE TO AGER ❑ OTHER A UTHORIZE D AGENT 13 <br /> LfAPPLicANT is not the BELL/NG 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Engineered Septic Design PAYMENT <br /> COMMENTS: �YA V ll 1 1 - _(N <br /> -ll W •1V'Y"� WV MAR 16 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: 2 <br /> `—/Z J <br /> ASSIGNED TO: ( I'\ EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: Z P I E: <br /> Fee Amount: © Amount Paid b 0 J Payment Date 3 I \k� <br /> Payment Type Invoice# Check# Received By: N & <br /> T/L �T« ss-scc��l�� � 7.�rs/-Y�.✓Ci� G�-13/�jz2n�J ten. <br /> EHD <br /> 48-01 <br /> REVISED 6-55-0-0 2 SERVICE REQUEST FORM <br /> REV <br />