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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ;:SERVICE REQUEST# <br /> 7154- <br /> OWNER/OPERATOR <br /> Paul Calosso & Fred Calosso CHECK if BILLING ADDRESS <br /> FACILITY NAME Calosso Property <br /> SITE ADDRESS 34443 N. Dry Creek Rd. Galt <br /> Street Numberoirect I StreetName cityCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 28499 Jack Tone Rd. <br /> Street Number I Street Name <br /> CITY Galt STATE CA zip 95632 <br /> PHONE#1 ExT. APN#009-020-03,009-060-03, LAND USE APPLICATION# <br /> (209 ) 369-2586 009-070-01,009-090-07,009-080-10 PA-1400209 <br /> 1009-090-05 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAT(# <br /> 407 W. Oak St. (209)369-0377 <br /> CITY Lodi STATE CA zip 95240 <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 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> n � <br /> APPLICANT'S SIGNATURE: PRS DATE: 2- <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IrAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmentaUsite 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: Review Soil Suitability Study PAYMENT <br /> COMMENTS: Z-/70115— 3} t L( '-5-J t"'> FEB 19 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P(E: j <br /> Fee Amount: '&169 -0-0 Amount Paid �(d� w Payment Date 2 tct t S <br /> Payment Type Invoice# Check# I,�3q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />