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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prof%—A FACILITY ID# SERVI EST# <br /> Bate L N/A <br /> OWNER/O <br /> See rtlent One CHECK if BILLING <br /> FACILITY NIVN/A <br /> SITE ADDRESS 88538 <br /> . Manthey Road French Camp 9 23 <br /> Street Number Direct( Street Name- City2i Code <br /> HOME Or MAILING ADDRESS '(If Different from Site Address) t <br /> 6;735 #�B � N. Herndon Avenue <br /> «+ Street Number Street Name <br /> CITYy' STATE' ZIP <br /> Stockton I k CA .95207 <br /> PHONE#1 ExT• rN# , / `LAND USE APPLICATION(209) 951-9900 ' 193-200-06 . ',' ` PA 06.00651 <br /> PHONE#21 ExT• ! ,� BOS DISTRICT LOCA ON E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE5TOR t 'r <br /> David Silva ,r te ,rf, CHECK if 13ILLING ADDRESS <br /> BUSINESS NAME <br /> None ai r. 'f, ' , P" 0 9 982-1114 E><T. <br /> r. f ' <br /> HOME or MAILING ADDRESS "'" r ; 1 1' '•, ' Fax# <br /> 6624 Chesa eake', Circle . '' x '(209) 982-5834 <br /> CITY ��. 1' J STATE CA ' ZIP 95219 <br /> Stockton <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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and IVYRAL 1 s. l <br /> APPLICANT'S SIGNATURE: A C DATE: 3/4- X0a7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATORINIANAGER ❑ OTHER AUTHORIZED AGENT® Buyer of Property <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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: vm' <br /> 1 <br /> COMMENTS: Review and Approval on an expedited basis of the Nei <br /> Anderson Soil Suitability Study and Nitrate Loading <br /> PA-0600651 for APN 193-200-06 <br /> r . . <br /> ACCEPTED BY: EMPLOYEE#: DAT?"k 1 O11 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> PIE:? <br /> Fee Amount: Z, S Amount Paid S 0 Payment Date <br /> I Payment Type `/ Invoice# Check# t{ 3 5 Received By: l V&— <br /> EFID 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11117/2003 <br /> i <br /> f <br />