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! 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential V .0,�(' 2->�- <br /> OWNER/OPERATOR <br /> Paul Schuler CHECK ifBILLING ADDRE33 <br /> FACILrrYNAME Schuler Residence <br /> SITE ADDRESS Stoneridge rd Tracy, CA 95304 <br /> 3960 Stmet Number DIMO. Street Name efty zip C <br /> HOME or MAILING ADDRESS (If Different from Site Address) Stoneridge rd <br /> 3956 stroet Number Stmet Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1 Exr• APN 0 LAND USE APPLICATION# <br /> ( 520)631-5720 3{- -/ F <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Paul Schuler CHECKif13ILLINGADDRESS❑ <br /> BUSINESS NAME N/A PHONE# FXT. <br /> HOME or MAILING ADDRESS 3956 Stoneridge rd FAx# <br /> I ) <br /> CITY Tracy STATE CA zip 95304 <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,STA and DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ZlP/Zo Zd <br /> PROPERTY/BUSINESS O WNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Ift1PPLICANT is not theBILLINGPARTY 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:Check install of water filtration system, Eheek-exs rtg-Septic-tank-ft T <br /> COMMENTS: Veil{� L,I Je, ", }/t, Sy5fF' '� T� '51 4 <_)rc;l t. �ySIrMS �1,l� r'✓ }i!e �1hc:s /. �- ('ALT 1 <br /> I 1lCLS}I�r Ems' �+r�r�;Ie I�,;Hr ►•rC D <br /> VY t I C(.- Il z r <br /> MAR 2 6 20 <br /> SAN JC)AQUIN <br /> 1-fe ON/0 OU TY <br /> TAI <br /> ACCEPTED BY: 1 Z' EMPLOYEE#: DATE: 3 �� ZCL b T <br /> ASSIGNED TO: j I,t EMPLOYEE#: DATE: 3/L E/4 0 ZQ <br /> Date Service Completed (if already completed): SERVICE CODE: D( P 1 E: <br /> Fee Amount: Amount Paitff45,22,0,9 Payment Date <br /> Payment Type /S —. Invoice# Check# 1670,S-7-735- Rec ived By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />