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SERVICE REQUEST SEPTIC <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN /OPERATOR 8L G PMM❑ <br /> Lav ' ✓ <br /> FACIuRY NAME <br /> ✓ ✓V 4 C <br /> SRE At10REss <br /> 110 2)- <br /> n,.,c.r oa.mon / 7 '�✓✓ear { I�� ` 4 J �') <br /> Mailing Address (I Different from Site Address) <br /> t L. <br /> CITY STATE Zip <br /> PHONE#1 Ecr. APN# LAND USE APP T10N# <br /> (� ) 4? � - ov Us5 — Ibv — �- L ,� —� - -73 <br /> PHONE 92 605 DwRa:7 LOGAmm COoE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR ���1 - 2 _ Busaw PARrYt <br /> To -7-z t - r,y <br /> Bus SS NAPE PHONE# W. <br /> Y ?, - �i Uv <br /> mNuIZI5 t& vhst c YC Z LO- ?6- 7 <br /> Crry STATE c y ZIP �Zo <br /> BILLING ACKNOWLEDGEMENT: I, the unamigned property or business own",openlor or author¢ad agent of same. acfaaekdgo that all sde andlor project speafic <br /> Pubuc HEALTH SERVICES EmwCtu.tENrAL HEALTH Drv6KN hourly Charges associated with this propa or ac tvay wia tm baed to me army business as identified on this form <br /> I also Certify Nat 1 nava prepared this app(cation and Nei Uta work to be performed wd be dine in aomrd•rcei with all SAM JOAoun CcUNTY Ordinanoe Codes.Standards,STATE and <br /> FE-ERAL laws. <br /> APPUCAHT SiGmrti E - DATE r /l' O CT <br /> PROPERTY! ❑ OPERATORIMAHAGER ❑ OOERAUMOR MAGENT ❑ 1 t�J' <br /> YAPPI.GVlTSnC(YY BatncPum.pmofcfeua Uwv loaVa6 npded Title <br /> ikUTHORIZATION TO RELEASE INFORMATION:When appicable.L Me omeroroperatar of the property bated at the above Brie address.hereby audnrtm Um rNmse of <br /> W1 and all results,geatechn"i data antler ermautwrtaUsge assessment intom alfon to Uw SAH JOA rH C0XM Pueuc WEALTH SERYKzs EKv ROrwQR1L HEALTH ONt"at soon <br /> as a k available and at On same Ume ri is provided b me or my represmmpvv. z• <br /> i <br /> TYPE OF SERYKE REWESTEO: _ <br /> c/ <br /> COMME.NiS: Sei � •.�� $,e 7 <br /> Z cj �f0 <br /> � � s2 -2 7C. <br /> R 112 0 <br /> w •wi -� <br /> w � d'1 � •�, APR �_ i 202 <br /> 9 � � . , .�. ,Ili,,�/� s y <br /> INSPECTOR'S SIGNA RE: CON RRACfOR'S SIGNATUR�i: y •. <br /> APPROVED aY: Estpw _I.. - DATE. 6 <br /> ASSIGNED TO: EYPLOTEE#: DATE: <br /> - Date Service Completed (rf already completed): SERVKECODE 06) <br /> Fee Amount - AmduntPaid Payment Date 4 <br /> Payment Type Invoice 9 Check# Received By: <br />