SR0083517 - Laserfiche WebLink

Home Browse Search

• Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # Single Family Residential ::::]I 119 E Weber Avenue as identified on this form. ( ) ASSIGNED TO: OWNER / OPERATOR CITY Stockton STATE CA ZIP 95202 Pock Lane Partners, LLC. CHECK if BILLING ADDRESS FACILITY NAME P / E: 2603 Fee Amount: $304.00 SITE ADDRESS 2706 Pock Lane Payment Type Stockton Invoice # 95205 Street Number Direction Street Name City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 119 E Weber Aveeggp,eme StreelNumber CITY Stockton STATE ZIP CA PHONE #1939 9025 J J J Exr' API# LAND USE APPLICATION # (209 ) 170-120-13 & 14 PHONE #2 ( ) Err. BOS DISTRICT LOCATION CODE REQUESTOR BILLING ACIfN'OWL,EDGEMENT: I, the undersigned property or business owner, operator or authorized CHECK If BILLING ADDRESS BUSINESS NA Nock Lane Partners, LLC. acknowledge that PHONE # ExT' ( ) (209) 939-9025 HOME or MAILING ADDRESS with this project FAX# 119 E Weber Avenue as identified on this form. ( ) ASSIGNED TO: CITY Stockton STATE CA ZIP 95202 I also certify that I have prepared this application an Surface and Subsurface agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. DATE: d that the work to be performed will be done in accordance with all SAN JoAQutN COUNTY Ordnlance Codes, Standards, STATE and FERE aws. APPLICANT'S SIGNATURE: h s DATE: 3 / PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IJ Agee4r,Jt IfAPPLICAAFT iS not the BILLINGP1RTY proof ofauthorization to sign is required Title 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 the same time it is provided to me or my representative. TYPE DP sERVICEREDUESTEo: Surface and Subsurface Contamination Report COMMENTS: Rod) REVISED 11/17/2003 ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 5523 P / E: 2603 Fee Amount: $304.00 Amount Paid Payment Date Payment Type Invoice # Check # Received By: END 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003