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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G�')o()-4-q<�q-q_ <br /> OWNER/OPERATOR <br /> Norman Gene Norton CHECKifBILLING ADDRESS El <br /> FACILITY NAME Norton Property <br /> SITE ADDR 9200 & 18350 S. Henry Rd. Escalon 95320 <br /> ZS Street Number Direction Street Name —City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Fo,)rQ'rA t rJ o�r Y Q T-H 6 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 5j. PcvGuST1NE � L 3 L 0 S�a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1760 ) 442-6944 229-260-27 & -30 PA-1800114 <br /> PHONE#2 EXT. BOS DISTRICT T7CATIONOCODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <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 STATE ZI P <br /> Lodi CA 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: 02 , DATE: zi-9 i <br /> PROPERTY/BUSINESS OWNER OPERATOR/4ANAGER ❑ 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, 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 environment to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at 41me It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: s�JO 2018 <br /> Eiy�tAQU�N v <br /> cojlz <br /> �N�Y <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> LW <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E <br /> 4L 1 <br /> Fee Amount: Amount Pa w Payment Date / <br /> Payment Type �� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />