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SR0079138_SSNL
EnvironmentalHealth
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2600 - Land Use Program
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SR0079138_SSNL
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Entry Properties
Last modified
11/12/2020 3:55:42 PM
Creation date
9/4/2019 6:06:41 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
FileName_PostFix
SSNL
RECORD_ID
SR0079138
PE
2601
STREET_NUMBER
3876
Direction
E
STREET_NAME
EMERSON
STREET_TYPE
RD
City
ACAMPO
Zip
95220
APN
00514523
ENTERED_DATE
5/21/2018 12:00:00 AM
SITE_LOCATION
3876 E EMERSON RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\wng
Supplemental fields
FilePath
\MIGRATIONS\E\EMERSON\3876\NL STUDY .PDF
Tags
EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Roopa Delapena CHECK If BILLING ADDRESS <br /> FACILITY NAME Delapena Property, proposed residence <br /> SITE ADDRESS 3876 E. Emerson Rd. Acampo 95220 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 1342 <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95241. <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 280-5404 005-145-23 <br /> 11 <br /> PHONE#j Ext. BOS DISTRICT r LOCATIOAL,CODE <br /> --]I <br /> C50 <br /> CONTRACTOR / SERVICE REQUESTOR OL L11 <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT.' <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 95240 <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 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 /> APPLICANT'S SIGNATURE: DATE: 0-j 2-1 Lu oc <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER A UTHORIZED AGENT❑ <br /> if APPLICANT is not the BILLING PARTY proof 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 environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study <br /> COMMENTS: <br /> May 21 �01�n <br /> QUIN GOON <br /> cvp,N JO R0%, <br /> ACCEPTED BY: C„ �(, EMPLOYEE#: DATE: <br /> ASSIGNED TO: J -�l EMPLOYEE#: DATE: <br /> Date Service Completed (if alr ady completed): SERVICE CODE: 5 Z� P I E: <br /> Fee Amount: b vo Amount Paid 3 C) Payment Date I , <br /> Payment Type C� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />
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