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SAN Jo COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Aeor)y ,(r33 <br />OWNER! OPERATOR Mr. Bob Schinke CHECK if BILLING ADDRESS 0- <br />FACILITY NAME Schinke Property <br />SITE ADDRESS 1150 <br />Street Number <br />N. <br />Direction <br />Fine Road <br />Street Name <br />Linden <br />City <br />95236 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 22040 <br />Street Number <br />3rd Ave. <br />Street Name <br />CITY STATE ZIP Linden CA 95236 <br />PHONE #1 EXT. <br />( 209)948-1411 <br />APN # <br />093-040-30 <br />LAND USE APPLICATION # <br />PA-02-630 <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Neil 0. Anderson & Associates, Inc. <br />PHONE # <br />(209 <br />EXT. <br />) 367-3701 <br />HOME or MAILING ADDRESS <br />902 Industrial Way <br />FAx # <br />(209 )369-4228 <br />CITY Lodi STATE CA ZIP 95240 <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, ATE and FEDERAL ws. <br />APPLICANT'S SIGNATURE: f, DATE: G <br />PROPERTY / BUSINESS OWNER': OPERATOR / MANAGER 0 OTHER UTHORIZED AGENT 0 <br />If APPLICANT 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. <br />TYPE OF SERVICE REQUESTED: Engineered Septic System Design Review -- .......1 ' <br />COMMENTS: .-A 5 ,FIPP <br />3./4% 0/7 <br />CC1' 04 % 713" <br />.011\1G°43141. <br />SPN 3°\ii\..0‘,IME PA" <br />EMPLOYEE #:c: y 52 ' nnt-1\ DATE: ,t.i. IV' c APPROVED BY: <br />ASSIGNED TO: <br />//& <br />----)--42 EMPLOYEE #: ec 36:2k DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6—.2_ Z___ PIE: 1., 2.-0 / <br />Fee Amount: 37_ Amount Paid at, 3-7D._. o p Payment Date 6 1 2,31 <br />Payment Type Type 1_,--" Invoice # Check # / SI, Received By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM