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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential OWTS <br /> OWNER/OPERATOR <br /> Moises Chavez CHECK If BILLING ADDRESS <br /> FACILITY NAME Second dwelling <br /> SITE ADDRESS 11668 s Union Manteca 95336 <br /> Street Number I Direction I Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# 204-030-07 LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Acorn Onsite, Inc . CHECK if BILLING ADDRESSO <br /> BUSINESS NAME Acorn Onsite, Inc . PH QN # EXT. <br /> y�5 447-5200 <br /> HOME or MAILING ADDRESS 2288 Buena Vista Avenue FAX# <br /> ( 92) 447-0919 <br /> CITY Livermore STATE CA ZIP 94550 <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: h I BATE: 6-29-21 <br /> ' <br /> PROPERTY/BUSINESS OWNERONziOPERATOR/MANAGER OTHER AUTHORIZED AGENT O Engineer <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 environmeI/site assessment <br /> information to the SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ' lt�me it is <br /> provided to me or my representative. Nr <br /> TYPE OF SERVICE REQUESTED: Review of Engineer prepared OWTS plan Q <br /> COMMENTS: <br /> sAN J 021 <br /> AL / <br /> p pMENO�NTY <br /> ARTMENT <br /> ACCEPTED BY:�� L EMPLOYEE#: DATE: 7 <br /> ASSIGNED TO: G EMPLOYEE#: DATE: -7 7 t <br /> Date Service Completed (if already completed): SERVICE CODE: S3 P 1 E: <br /> Fee Amount: of Amount Pai 4. <br /> 0� Payment Date <br /> Payment Type /IInvoice# Check# N,9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />