Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# CA SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Enrique Morales CHECK if BILLING ADDRESS <br /> FACILITY NAME Morales Property <br /> SITE ADDRESS 1008 N. White Ln. Stockton 95215 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 640-5546 101-070-30 <br /> PHONE#2 EXT. BOS DISTRICT yy � LOCATION CODE <br /> ( ) �—! oC� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 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 wo to be performed will be done in accordance it <br /> all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL law . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER /MA GER OTHER AUTHORIZED AGENT❑ <br /> If APPLICAN is not the BILLING 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study CC "• <br /> COMMENTS: 46V 20 <br /> �Q <br /> %iyl,°gQ�iN 21 <br /> H T h'D pQRAM 4 <br /> ENr <br /> ACCEPTED BY: -�-7-7 1- L EMPLOYEE#: DATE: y/;J ,7 1 <br /> ASSIGNED TO: DA <br /> EMPLOYEE#: DATE: (4 1)o a <br /> Date Service Completed (if already completed): SERVICE CODE: P E: oj <br /> Fee Amount: U S Amount Pa �ox, 0D Payment Date <br /> Payment Type Invoice# Check# Received By:L1,9± <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />