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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property prepared septic system design. Acorn Onsite, Inc. FACILITY ID # SERVICE REQUEESTT # Single family residential 925)447-5200 HOME Or MAILING ADDRESS FAX # LA0 J� OWNER / OPERATOR ( 925}447-0919 CITY STATE ZIP Livermore CA 94550 T MENT CHECK If BILLING ADDRESSIM FACILITY NAME EMPLOYEE#: DATE: y / a John Waiters ASSIGNED= SITE ADDRESS E Section Date Service Stockton SERVICE CODE: 3325 Street Number P / E: Direction Street Name Amount Pak dt� City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4151 Degas Avenue Payment Type !te Invoice # Street Number Check # LTJ b4216 1 Street Name CITY STATE ZIP Stockton CA 95206 PHONE #1 EXT. APN # LAND USE APPLICATION # ( , 117MM33 PHONE #2 c , EXT. BOS DISTRICT f LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR prepared septic system design. Acorn Onsite, Inc. CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT, Acorn Onsite, Inc. 925)447-5200 HOME Or MAILING ADDRESS FAX # 2288 Buena Vista Avenue ` o QU/ NEA T� DEP4RN�,AL ( 925}447-0919 CITY STATE ZIP Livermore CA 94550 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL IIEALTH 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 COUNTY Ordinmrce Coder, Slnrtdards, STATE anc APPLICANT'S SIGNATURE PROPERTY / BUSINESS OWNE: R the work to be performed will be done in accordance with all SAN JOAQUIN laws. APPLICANT is not DATE: OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If !/re BILLING PARTY, proof of rrrrlhoriZalion /n sign is required Tile 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 t�y in_e time it is provided to me or my representative. Q n _ ,►'!FA/ �. TYPE OF SERVICE REQUESTED: Plan review of engineer prepared septic system design. COMMENTS: APR SAN ?o?i ` o QU/ NEA T� DEP4RN�,AL T MENT ACCEPTED BY: ��' �, / _- EMPLOYEE#: DATE: y / a ASSIGNED= ! EMPLOYEE #8 DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: 3© Amount Pak dt� Payment Date Payment Type !te Invoice # Check # LTJ b4216 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003