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r+ M1 USAN JOAQUTA�, UNTY ENVIRONMENTAL HEALTH 17 11TMRNT <br /> SERVICE REQUEST , <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTE e- <br /> # <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS <br /> Mr- Vi fflaQnte�s <br /> FACILITY NAME <br /> Virarnontes Propert <br /> SITE ADDRESS ]Street4454 N State Route 88 TLodi 95240 <br /> Number Direction reef me Ci Zi ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) P.O. BOX 2244 <br /> Street Number tr et-Name- <br /> CITY STATE / ZipL!2di CK, 95241 <br /> 1 <br /> EXT, APN# - LAND USE APPLICATION# � <br /> PHONE#1 � I} <br /> ( ) f 0 �--53E063-160-11 PA-03-543 } <br /> EX7, BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> PHONE# EXr. <br /> BUSINESS NAME 367-1701 <br /> HOME or MAILING ADD RESi FAX# <br /> 209 369-422.8 (2091369-4228 <br /> CITY <br /> STATE CA ZIP <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 /> 1 also certify that 1 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: <br /> PROPERTY/BUSINESS OWNER 13OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />' If APPLICANT 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 environmental/site 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 /> l provided to me or my representative. L-IC�t.L 1 0 <br /> t � <br /> TYPE OF SERVICE REauESTED: Engineered Septic System DrawiN Review <br /> COMMENTS: JVF <br /> CV JO 2 <br /> SAN dOAUIN COUN <br /> fd NTAL <br /> i <br /> APPROVED BY. [ l V L IF HEALTH QEFMO E#: <br /> ASSIGNED TO: M rQ°( A/ /{ EMPLOYEE#: S DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE;. -,)- F?-2- PIE: 'Y2- 0/ <br /> Fee Amount: Amount Paid (� payment Date <br /> '9- 3 <br /> !fib . 2 37Z. .t <br /> Payment TypeInvoice# Check#. Rec�ved By: <br /> d r <br /> EHD 48-01-025 SERVICE REQUEST F RM <br /> REVISED 6-5-02 �� <br />