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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Agricultural !(Z'00 <br /> /( OD � O <br /> OWNER/OPERATOR �— (/ <br /> Redeeming Way LLC c/o Jim Ehlers CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 403 W Woodbridge Road nodi 95258 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO Box 895 <br /> Street Number Street Name <br /> CITY Woodbridge STATE CA ZIP 95258 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 )481-5770 015-020-56 <br /> L4-aOW2[3 ( Sw) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) q ] <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Cecil Dillon CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME Dillon & Murphy Engineering PHONE# EXT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS PO Box 2180 Fax# <br /> CITY Lodi STATE CA ZIP 95241 <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 JOAQUtN <br /> COUNTY Ordinance Codes,Standards,STATE and F E la s. <br /> APPLICANT'S SIGNATURE: DATE: I ZZ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® oject Lgineer <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 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 tomeoorrsmy�representative. <br /> TYPE OF SEf�fAXIMUT J T,Q <br /> COMMENTS: RECEIVED <br /> JAN 2 8 2022 J V/ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEP TM <br /> ACCEPTED BY: EMPLOYEE#: DATE: IIID <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: PIE: 6 <br /> Fee Amount: J� Amount Paid [� Payment Date / 2� <br /> Payment Type Invoice# Check# 22 S Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />