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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property q <br /> Rural Residential <br /> OWNER/OPERATOR ! <br /> CHECK If_BILLINGADDRESS <br /> Janet E. Smythe <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 14701 Street Number Direction C01713crOp011SStreelName Stockt 521 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> � . . Slreet�urnber Street Name <br /> CITY STATE ZIP <br /> ` <br /> PHONE#I YEar �. APN# LAND USE PLICATTT�IIIION# <br /> OL f <br /> [209':1 463-2527 (,Q <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> i <br /> 1 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CHECK if_BILLINGADDRESS <br /> Steven G. Mackey <br /> Bu51N S NAME PHONE# Ems' <br /> Diel on & Murphy 12091 334-6613 19 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 2180 (209 ) 334-0723 <br /> i <br /> CITY Lodi STATE CA zip 95241 <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 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 1 also certify that 1 have prepared this app!" ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and FEDERAL l S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS QWNER❑ PERATOR I MANAG OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,prof of authorization to sign is required Title <br /> AUTHORIZATION 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 environmentaVsile 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: .7a 1 L. w t 1-f4 a j �( rV STIAX) 4�7Y E <br /> COMMENTS: i7 L <br /> YMIZ <br /> vEt� MAY 1 8 2005 <br /> RCC <br /> 4 SAN JOAOUIN-COUNTY <br /> ENVIRONMV -NTAL <br /> y •iuN 7 ZOOS HEALTH DEFfARTMENT <br /> 1P1 ( ++ i <br /> ACCEPTED BY: DATE: <br /> j ASSIGNED TO: HEA D T 5 <br /> 14 1. DATE: Q 18 <br /> Date Service Completed (if already completed): SERVICE CODE: s?f 2. P1 E: Z(. oI <br /> k Fee Amount: 00 Amount Paid 6I ayment Date JG b 5 `710 l <br /> Payment Type Invoice# Check Received By. l <br /> END 48-02-025 -- ,_a.. ,� Y S - ,,, � r SR FORM(Golde <br /> REVISED 1 111 712 003 <br /> 4 <br />