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• r - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Home W '7q�'� OWNER/OPERATOR Jacob Babauta and Allison Ortega-Schafer CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS 4849 Mosher Dr Stockton 95212 Street Number I Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Q Street Number Street Name CITY STATE ZIP If�-c PHONE#1 ExT• APN# LAND USE APPLICATION# D (209 1 607-0933 D p 1 g Jut 23 PHONE#2 Err. BOS DISTRICT u LO �� (209 ) 607-3080 –I HFq ON00 NTy CONTRACTOR/ SERVICE REQUESTOR gRTAA REQUESTOR Jacob Babauta and Allison Ortega-Schafer CHECK if BILLING ADDRESS BUSINESS NAME PHONE# ExT• 209 607-0933 HOME or MAILING ADDRESS FAX# 4849 Mosher Dr ( ) CITY srockta, STATE cafiromla ZIP 95112 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONNIE.NTAL HEALTH Dr.PARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQl1rN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 'e" dam' DATE:luly 21, 2021 PROPERTY/BUSINESS OWNER 21 OPERATOR/(MANAGER ❑ OTHER AUTHORIZED AGENT❑ /'APPLIC,INT is not the BILLING PARTY',proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. /' TYPE OF SERVICE REQUESTED:Septic cite Visit — ve!lfiC4)��o+� 6e, � rrt ti �Ime, 10(e }�-mi Tom/ d new 1' COMMENTS: OvFf Or C^J>1�TL;cjOr 40 joct,to gnCl uaca.(er Pot tlan5 OF the ea- }fin ynosf kc c►t IMP an�A p,+. .Z_sPr4 Jur wall rew>CJ c4f5;fe1n[F.s {'/Jr►7 line, Q nc/p,E N�- 171'3'pe jK c,nCl Sty✓Mute tv help In �efetl++,niltJr if Pr PosP�p�o� �' !ll'+'leet se°tbyel�S , /Poch liheS- ACCEPTED BY: I----/� I_ L. EMPLOYEE M DATE: 71W 3 ASSIGNED TO: A EMPLOYEE M DATE: 71d3 L,4 Date Service Completed (if already completed): W . SERVICE CODE: O P I E: Fee Amount: Ca Amount Paid IQU Payment Date 7 J Payment Type v' A-- I Invoice# Check# ��8'oZozZ Rece ed By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003