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Community Development Department, Permit Center
City Hall y 425 N. El Dorado Street y Stockton, CA 95202-1977
REQUEST FOR REFUND
State Zip Code
Receipt #
Permit #
Name:
Address:
City
Telephone number:
Amount of refund requested:
Date paid to City
Total amount paid:
Situs address:
Reason for requesting refund:
Contact Name:
I Certify under penalty of perjury that the information provided is true and correct.
Subscribed and sworn on this __________ day of __________________________ , 20 _______________________________________________________________________ Customer Business Name
_______________________________________________________________________ Signature
FOR OFFICE USE ONLY
Approved by: _______________________________ Date: ________________ Department Head or Designee (If over $1,000.00)
Approved by: Date:
Chief Financial Officer or Designee (If over $1,000.00) Account No:
Trust Accounts – please forward to Accounting for Approval Ext
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Attachment A
The Five Corners Group
15100 S. Jack Tone Rd.
Manteca CA 95336
209-982-5248
$27,116.45
09/20/24
$27,116.45 P24-0177
9277 S State Route 99 W Frontage Rd
Project has been put on hold... will reapply at a later date.
Ryan Van Groningen
16th December 25
The Five Corners Group LLC