Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 520077Liqk <br /> OWNER/OPERATOR Stanley Enterprises LP CHECK if BILLING ADDRESS x❑ <br /> FACILITY NAME Stanley Enterprises Property <br /> SITE ADDRESS 14629 E. Wildwood Rd. Stockton H53-15 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1910 Black Slate Ct. <br /> Street Number Street Name <br /> CITY Gold River STATE CA ZIP 95670 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (571 ) 216-1234 Jerilyn Stanley 203-030-02 PA-1600206 <br /> PHONER ExT. BOS DISTRICTLOCATION CODE <br /> ( > 4 R <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA ZIP 95240 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: h J (// � , DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AWTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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,Kne time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: <br /> go-er7 ��aca�����. <br /> /h.Fh. csGrrrTc >0�ONQ ZM <br /> N� <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 61 <br /> Fee Amount: 2 Amount Paid Z7 Q , Payment Date �c ti. <br /> Payment Type Invoice# Check# 12-2-Ce Received By: °J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />