Laserfiche WebLink
San Joaquin (jnty Environmental Health D kRTMENT <br />Type of Business or Property <br />Check if Billing Address3140 Peacekeeper Way, McClellan, CA 95652 <br />Direction <br />Street Number <br />StateCity 95652CAMcClellan <br />Ext.Land Use application #APN # <br />Location CodeBOS DistrictExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />995-5288 <br />State 95608 <br />Type of Service Requested: <br />Comments: <br />Employee#:Accepted By: <br />Amount Paid <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />RECEIVED <br />OCT 1 4 2016 <br />West Grant Line Road <br />Street Name <br />95376 <br />Zip Code <br />489-8009 <br />Zip i <br />New apartment project/complex <br />Owner / Operator <br />Gateway Crossing, LLC <br />Facility Name <br />Grantline Road Apartments (phase 1 - East) Gateway Crossing <br />Site Address <br />3580 West Grantline RoadStreet Number <br />Home or Mailing Address (If Different from Site Address) <br />3140 Peacekeeper Way <br />SERVICE REQUEST <br />FACILITY ID # <br />Phone# <br />(916) <br />Fax# <br />( 916 ) <br />CA <br />Tracy <br />________________ City <br />Peacekeeper Way <br />_______________Street Name <br />ZIP <br />Eagle Pools, Inc. <br />Home or Mailing ADDRESS <br />3329 Garfield Ave. <br />City <br />SERVICE REQUEST # <br />Phone#2 <br />(____) <br />Phone #1 <br />( ) <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DFPARTn,1EMT <br />oate-j^- <br />Date: jo <br />|p,E:3^o7~~ <br />Received By: <br />Check if Billing Address El <br />Carmichael__________________ <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 tins application and that the work to be performed will be done in accordance with all S.AN JOAQUIN <br />County Ordinance Codes, Standards, State and Federal laws. <br />____________ <br />Assigned to: ________ <br />Date Service Completed (if already completed): <br />Fee Amount: ___________ <br />Payment Type | lnvoice# <br />Employee#: <br />| Service Code: <br />^>55~(p.fcQ | PaymentD^ <br />| Check# <br />Requestor <br />Mike Nantze <br />Business Name <br />APPLICANT’S SIGNATURE: DATE: Oct. 10,2016------------------- <br />PROPERTY/ BUSINESS OWNErD OPERATOR/ MANAGER □ OTHER AUTHORIZED AGENT [3-------PteS., Eagle POOlS, InC.------- <br />If Applicant is not the Billing Party, proof of authorization to sign is required Tute <br />A UTHORIZATION 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 assessmen <br />information to the s\n JOAQUIN COUNTY ENVIRONMENTAL Heal™ Department as soon as it is available and at the same time it is <br />provided to me or my representative. <br />new apartment pool/spa plan check