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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 Development - 254 homes —+-qc� <br /> OWNER/OPERATOR <br /> Lennar Homes of California, LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Mountain House Creeks - Tract 4097 <br /> SITE ADDRESS N I Estes Way Mountain House 95391 <br /> 350 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 025-327-8318 256-040-01 PA 2100089 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORSAMEAS OWNER <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME SAME AS OWNER PHONE# SAME AS OWNtR <br /> HOME or MAILING ADDRESS SAME AS OWNER FAx# <br /> CITY STATE ZIP <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 andAt the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA E and ER L laws. <br /> APPLICANT'S SIGNATURE: DATE: 9/2/2022 <br /> PROPERTY/BUSINESS OWNER® OP ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 proppr, � A�„at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme ev ment <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. SEP U 9 20 <br /> TYPE OF SERVICE REQUESTED: PA 2100089 - Condition 5a, Surface/Subsurface review SAN JOAQUIN COUNTY <br /> COMMENTS: HEALTH DEPARTMENT <br /> Per PA 2100089 - Condition 5a, Surface/Subsurface review, it is required for Lennar to <br /> submit and the Environmental Health Department to review documentation to satisfy <br /> surface/subsurface contamination reporting requirements. <br /> Phase 1 Modified ESA (dated March 2021 and January 2022) provided for documentation. <br /> ACCEPTED BY: EMPLOYEE#: DATE: 20 V— <br /> ASSIGNED TO: EMPLOYEE#: DATE:Q/ 9 D <br /> ZIP- <br /> Date Service C plet d if alre y completed): SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid Pa ment Date <br /> Payment Type C . r Invoice# Check# ul Received By: <br /> EHD 48-02-025 VT !��e[�' �' -7 (/ 4 1 q .� ! SR FORM(Golden Rod) <br /> REVISED 11/17/2003 /lK 2 <br />