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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />Almond Orchard <br />PHONE# <br />209 <br />EXT' <br />334-6613 <br />S Q po g C5 0 J <br />OWNER/ OPERATOR <br />Sammy and Heather Cox 2015 Trust <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZIP 95241 <br />SITEADDRESS 15780 <br />N <br />Clements Road <br />I <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PO Box 1592 <br />Street Number <br />Street Name <br />CITY Linden <br />STATE CA ZIP 95236 <br />PHONE #1 EXT. <br />( 916 ) 415-5236 <br />APN # <br />053-190-01_ <br />LAND USE APPLICATION # <br />�7 -) 5 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTR CT1-1 <br />LOCATION C DE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR James Selke <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Dillon & Murphy <br />PHONE# <br />209 <br />EXT' <br />334-6613 <br />HOME or MAILING ADDRESS PO Box 2180 <br />FAx # <br />CITY Lodi <br />STATE CA <br />ZIP 95241 <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 appliSation applicationand that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, rE:ZL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />03-11-2022 <br />PROPERTY / BUSINESS OWNER❑ OPETO / AGER ❑ OTHER AUTHORIZED AGENT ® Project Engineer <br />IfAPPL/CANT 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 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. n <br />TYPE OF SERVICE REQUESTED: SOff6ce �d SLib sulfGLe GOl1fc„�•+ha�i�n RepQr+ Review REC61-id <br />MAR 16 20 <br />SAN JOAQUIN <br />HEALTH <br />ACCEPTED BY: ��� L— Z-- EMPLOYEE M DATE: <br />ASSIGNED TO: I rC N cv k EMPLOYEE #: DATE: 3// (_/a <br />Date Service Completed (if already completed): SERVICE CODE:S -)3 P I E: a4 J3 <br />Fee Amount: � 3u y Amount Paid 3 p _ Payment Date <br />Payment Type /� &; _ I Invoice # Check # !3 „� Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />