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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT SERVICE REQUEST Type of Business or Property BuSINE99 NAME FACILITY ID # REQUEST # County Park CITY STATE zip PUMP, SEWER LINE, ELECTRICAL elERVICE C) Li OWNER /OPERATOR County San Joaquin DELTA SAiV , 21 of CHFrK If BII.t.Mr, AnDRFSSO FACILITY NAME Micke Grove Regional Park Delta Shelter H SITEADDRESS EMPLOYEE #: DATE: Micke Grove Road Lodi 95240 11793 Street Number Direction Street Name PIE:LODI City Zito) Code HOME or MAILING ADDRESS (if Different from Site Address) Paymont DatO 3 as N. San Joaquin Street, Suite #590 44 Street Number Street Name CITY Stockton STATE CA ZIP 95202 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 953-7046 059-100-02 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) 7i] CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joshua Hernandez Zavala - SJC Capital Projects Administration CHErKif BILLING ADDRESS® BuSINE99 NAME PHONE EXT. HOME or MAILING ADDRESS FAX # t ) CITY STATE zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: / DATE: 1/11122 PROPERTY/ BUSINESS OWN ER ERAT R/ n'IANAGER ❑ OTHER AUTHORIZED AGENT ® Engineering Assistant II If APPLICANT is 1101 the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 COUN'IY ENVIRONMENTAL HEAL'I'Ii DEPAK'rMEN'1as soon as it is available and at the sante time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Septic System - BP -2104339— Eli,;. lo i -e re/'l S s j rn,7 R'' v ! r" J COMMENTS: Fc c CF/V,F� INSTALL SEWER MANHOLE, SUMP PUMP, SEWER LINE, ELECTRICAL EB 03 FOR PUMP STATION FOR SJC MICKE GROVE DELTA SAiV , 21 SHELTER RESTROOM G)OI H ACCEPTED BY: Z_ L EMPLOYEE #: DATE: As91GNED TO: i! t)^ k' ' EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: ;, PIE:LODI Fee Amount: 4' � JL] Amount Paid A _. Paymont DatO 3 as Payment Type g s" Invoice # GNoeir# 000 IT -e Received By: 0�wJ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003