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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 R-R C' ")C���Y7��� I n <br /> OWNER/OPERATOR y <br /> Paul Armanino CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �476North Patton Avenue �Ckton 9�15StreDirection Street Name <br /> Zi <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY <br /> STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) 103-130-1 j <br /> PHONE#2 EXT, <br /> ( ) BOS DISTRICT +7[LOCATION CODErS <br /> �' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y��y <br /> Tonya Scheftner CHECK if BILLING ADDRESSLU <br /> BUSINESS NAME Petralogix Engineering,Inc. PHONE# EXT. <br /> 209 1 770-0731 <br /> HOME or MAILING ADDRESS FAx# <br /> 26675 Bruella Road <br /> CITY ( ) <br /> Galt STATE CA ZIP 95632 <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,STATE and FEDERAL laws. <br /> f., <br /> APPLICANT'S SIGNATURE: <br /> ( J DATE: October 17, 2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Geologist <br /> IfAPPL/CANT i.s not the RILLAVG 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 environmentaUsite 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: Nitrate Loading/Soil Suitability Study Review PAYMENT <br /> COMMENTS: <br /> Submitting on behalf of client property owner. Ze,e lueC ►t 1'U r✓I'+'le°I °`1 q/t7�jl, 'QCT 2021 <br /> :'AN JOAQUIN COUNTY, <br /> ENVIRONMENTAL' <br /> ,IEALTH DEPARTMENT <br /> ACCEPTED BY: �� '` EMPLOYEE#: <br /> DATE: /O/l eib/ <br /> ASSIGNED TO: S EMPLOYEE#: <br /> DATE: i JI/CyIT;I <br /> Date Service Completed (if already completed): SERVICE CODE: , P E: <br /> E,Uvf <br /> Fee Amount: 0 Amount Paid 7j -- Payment Date L 0 G L <br /> Payment Type �)L S`� Invoice# C # 3 3 ?j' j l <br /> V <br /> � � Received By: <br /> EHD 025 <br /> REVISEDSED 11/17/2003 c SR FORM(Golden Rod) <br />