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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # ELEMENTARY SCHOOL PHONE# EXT. 916 355-9922 HOME Or MAILING ADDRESS 1110 Iron Point Rd. OWNER I OPERATOR CITY Folsom STATE CA zip 95630 RIPON UNIFIED SCHOOL DISTRICT DATE: l U(1, 7 l CHECK if BILLING ADDRESS❑ FACILITY NAME COLONY OAK K-8 SCHOOL P! E: Zv Fee Amount: J SITE ADDRESS 22241 Pa meat Date y -7 MURPHY RD. Invoice # RIPON 95366 Street Number Direction Street Name City Zic Code HOME Or MAILING ADDRESS (If Different from Site Address) -' t , ! • ` Street Number '� ` Street Name CITY ` STATE - � zip q5G PHONE #1 EXT. APN #� LAND USE APPLICATION # ( 209) 599-7145 `t 51 (UJ 3 5 PHONE#2 Ext. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Max Medina CHECK if BILLING ADDRESS BUSINESS NAME WLC Architects, Inc. Itiy 1320V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE-PARTMEN1 PHONE# EXT. 916 355-9922 HOME Or MAILING ADDRESS 1110 Iron Point Rd. FAx# (916)355-9950 CITY Folsom STATE CA zip 95630 BILLING ACKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONNIENTAi. HEAIAII DI'.PARTMP.N't hourly charges associated with this project or activity will be billed to me or my business as identified on this fomT. 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 COUNTY Ordinance Codes. Standen ST -ATI- r FEDI= , I. law. APPLICANT'S SIGNATURE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O1lIF:RAI'TIIORI%ED:�GF:\"I' ,b1rLr}� ,(j Q If APPLICANT is trot the 13ILLL\G PARTY. proof ojauthorizafion to sign is required Title w 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 C'OIJN I N' ENVIRONMr.NTAI. HHAIA I I DI PARTMEN"r as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Review of Engineered Septic System RECEIVED COMMENTS: Itiy 1320V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE-PARTMEN1 ACCEPTED BY: �� {r C t EMPLOYEE #: U DATE: 7 -(A-k-7 ASSIGNED TO: EMPLOYEE #: DATE: l U(1, 7 l Date Service Completed (if already completed): SERVICE CODE: 15 Z� P! E: Zv Fee Amount: J Amount Paid .S J L� — Pa meat Date y -7 Payment Type Invoice # Check # Received By: EHD 48-02.025 REVISED 11/17/2003 SR FORM (Golden Rod)