Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />CHECK if BILLINGADoREss� <br />SERVICE REQUEST # <br />School <br />PHONE ILA <br />916 747-4410 <br />99 o0s35 lis <br />OWNER/OPERATOR parry Dalzell <br />CHECK if BILLINGADOREss© <br />FACILITY NAME Central Valley Baptist Church <br />STATE CA ZIP 95826 <br />SfTEADDRESS 10948S <br />I <br />Airport Road <br />Payment Date <br />Manteca <br />95336 <br />Stmt Number <br />OlncUon <br />Str"I Name <br />city <br />Zip Code__ <br />HOME OT MIULWG ADDRESS (H Dfffarsrrt from Site Address) <br />A <br />w <br />trt Nu r <br />f <br />CITY <br />STATE ZIP RE - WI <br />I VJE�6 <br />PHONE:I`i ExT <br />( ) <br />APN 8 204-020-004 <br />LANG USE APPLICATION 0 A�� O <br />O1 % 2 021 <br />PHONE#2 ExT <br />BOS DISTRICT E �Q Jr►[aJ COOS <br />( ) <br />N iRCN CC7NT <br />CONTRACTOR / SERVICE REQUESTOR "tPART MRNT <br />REQUESTOR Rick McCauley <br />CHECK if BILLINGADoREss� <br />BuSINEss NAME RSR Consulting <br />EMPLOYEE #: <br />PHONE ILA <br />916 747-4410 <br />HOME or MAULING ADDRESS 3609 Bradshaw Rd #311 <br />EMPLOYEE #: <br />FAx# <br />( ) <br />CITY Sacramento <br />STATE CA ZIP 95826 <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 ENVIRONMFNTAI. 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 />1 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!/_ N {C �+�DATE:; 3/31/2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ bTI1ERAuTnORIZEDAGENT 3 Consultant <br />If APPLICANT is not the 814LING A4B proof of authorization to sign is required Title <br />AVTHORIZ&IIQN 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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Would like to submit plans for an advance treatment unit (Hoot Aerobic Treatment <br />System) with drip tubing dispersal to handle the waste water requirements for the <br />4 bedroom residence being built on the this property. Goal is to obtain a septic <br />installation permit. <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />AssioNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: fl <br />Amount Pal 3 , Q� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 1233x5 / q <br />Received By. <br />EHD 48-02.025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />