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SAN JOAQUI—COUNTY ENVIRONMENTAL IIEALTH-'-- —'PARTMENT <br /> r SERVICE:~RCOUEST <br /> Type of Business or Property FACILITY ID# SERA E.R Q E�# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS ^ <br /> Mr- BmUlmern <br /> FACILITY NAME <br /> 1—Bi lier-i.-Pro pert.—._. ---- <br /> - • -SITEAriDRE5s 17815E State Route 88 Clements 95227 <br /> - Street Number Direction Street Name Ci - Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. BOX 604 <br /> Street Number Street Name <br /> CITY STATE zip <br /> Qlements CA 95227 <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> f 019 <br /> PHONE#2 EST. <br /> CONTRACT( <br /> REQUESTOR - � { <br /> Dave Welrh <br /> BUSINESS NAMENami 0, Anderson and <br /> - -..- <br /> HOME or MAILING ADDRESS <br /> 209 369-4228 <br /> CITY <br /> Lodi <br /> BILLING ACKNOWLEDGEMENT: I, the undersiM <br /> acknowledge that all site and/or project specific ENVIR `•ct <br /> or activity will be billed to me or my business as identit f� �/ , _ <br /> I also certify that I have prepared this application and trI � IN <br /> COUNTY Ordinance Codes,Standards STATE and FEDF <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANA? <br /> APPLlC,9NT is notot the BILLING PARTY,P1 <br /> AUTHORIZATION TO RELEASE INFORMATIOI <br /> If <br /> above site address, hereby authorize the release of a <br /> I information to the SAN JoAQunv COUNTY ENvixoN>,9EN �7ja � <br /> provided to me or my representative. <br /> TYPE OF S RVICE REQUESTED: Soil Suitability Study <br /> l <br /> coM s: Please review the following Soil Sui <br /> fee of$186. If you have any questie <br /> Dave S��/O,5 �' <br /> APPROVED sy: Ll LJ f ♦�/�� /9� y� <br /> F ASSIGNED TO: <br /> /in � ✓ �f q` �•� � �� <br /> Date Service Completed (if already completed): <br /> 51-1/ <br /> Fee Amount: �(�. vp Amount Pat <br /> Payment Type ✓ Invoice# <br /> EHD 48-01-025 �. <br /> REVISED 6-5-02 <br /> r <br /> I <br />