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% 5 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �l'a sKoo493ag <br /> OWNER/OPERATOR Verne Schultz <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Oakdale 95361 <br /> 31103 E Grooms Road <br /> Sheet Number Stmet Name City Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) 31146 East Lone Tree Road <br /> Street Number trees Name <br /> CITY Oakdale STA CA <br /> Zip 95361 <br /> Ea.PHONE#1 EAPN# LAND USE APPLICATION# <br /> 1209 1847-0516 207-280-03 PA-06-319 <br /> PHONE#2 ExT BOS DISTRpIICT�� I LOCATION CODE <br /> ( ) W <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Verne Schultz CHECK MBILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> 209 1 847-0516 <br /> HOME Or MAILING ADDRESS FAX# <br /> 31146 East Lone Tree Road (209) 848-1301 <br /> CITY Oakdale STATE CA ZIP 95361 <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 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: a airp <br /> PROPERTY/BUSINESSOWNER❑ O ERATOR/&NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,/fAPPLICA,T 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 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: Soil Suitability Study& Engineered <br /> Septic Plans PAYMENT <br /> COMMENTS: I �rlb ;;- /A/,wf6it/ �yyl///�i,/J/l ED <br /> (/,� i/\�"/'�/ JAN 0 4 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEP <br /> APPROVED 6Y: EMPLOYEE#: DATE: fr <br /> ASSIGNEDTO: /17 �( EMPLOYEE#: d S DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: V Amount Paid v , 0(_) Payment Date ` L.F <br /> Payment Type \� Invoice# Check# -2-2 Z© Received ByIN c'j <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />