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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> School �''' <br /> OWNER/OPERATOR <br /> Parry Dalzell CHECK It BILLING ADDRESS© <br /> FACILITY NAME Central Valley Baptist Church <br /> SITE ADDRESS 10948S Airport Road Manteca 95336 <br /> Street Number D rac n Streot Name C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PAStreet Number t Name <br /> CITY STATE ZIP ECEI <br /> PHONE01 EXT APN IY 204-020-004 LAND USE APPLICATION 0 "PR�` z <br /> 02, <br /> PHONES EXT BOS DISTRICT IT CODE <br /> IRAN COUNT <br /> CONTRACTOR / SERVICE REQUESTOR PARTrrENt <br /> REQUESTOR Rick McCauley CHECK if BILLING ADDRESS <br /> BUSINESSNAME R&R Consulting PHONE# EXT. <br /> 916 747-4410 <br /> HOME or MAILING ADDRESS 3609 Bradshaw Rd #311 FAx# <br /> CITY Sacramento STATE CA ZIP 95826 <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 HFAi.TH 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: C1 DA-i E: 3/31/2021 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 1TIIERAUTIIORIZEDAGENT 13 Consultant <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 environmental/site assessment <br /> information to the SAN JOAOUIN 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: <br /> COMMENTS: Would like to submit plans for an advance treatment unit (Hoot Aerobic Treatment <br /> System) with drip tubing dispersal to handle the waste water requirements for the <br /> 4 bedroom residence being built on the this property. Goal is to obtain a septic <br /> installation permit. <br /> ACCEPTED BY: EMPLOYEE C DATE: <br /> ASSIGNED TO: Alwav EMPLOYEE#: DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: D Amount Pal 3 �� Payment Date <br /> Payment Type ; Invoice# Check# 23305I4 q Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />