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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # dark Milani, P.E SERVICE REQUEST # Residential SAN JOAOUIN C ENVIRONME PHONE# EXT. ' 1 � yU i v OWNER / OPERATOR ❑ Spc Land Development (Sally Thronber) CHECK If BILLING ADDRESS FACILITY NAME 2655 Stanwell Drive, Suite 105 18851 Queirolo Rd Lathrop/ APN 241-020-069 San Joaquin County) ( 925) 674-9279 SITE ADDRESS ------ Queirolo Road ASSIGNED TO: L 5 Lathrop 95330 18851 Street Number Direction Street Name P / E: City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) I 3 948 Street Number Reliez Station RoaChtreet Name CITY Lafayette STATE CA ZIP 94549 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 708-3557 241-020-169 (SanJoaquin Cty) TPM -21-165, Referral SU0014818 PHONE#2 EXT• BOS DISTRICT �[Lo�CATIONDE 3� CONTRACTOR / SERVICE REQUESTOR REQUESTOR dark Milani, P.E CHECK If BILLING ADDRESS® BUSINESS NAME SAN JOAOUIN C ENVIRONME PHONE# EXT. Milani & Associates 925 674-9082/925-330-7642 HOME Or MAILING ADDRESS FAX # 2655 Stanwell Drive, Suite 105 ( 925) 674-9279 "Concord STATE CA ZIP 94520 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Mark. Mi. 441i., P.E. PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ DATE: June 21, 2022 OTHER AUTHORIZED AGENT ® Senior Env Supervisor If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assPAy ftNT information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same REPO ED provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: SAN JOAOUIN C ENVIRONME HEALTH DEPAR Site inspection to verify actual locations for septic tanks, leach field and domestic water well to comply with San Joaquin County Environmental Health Department, "Conditions of Approval for TPM -21-165, Project Referral SU0014818,18800 & 18851 Queirolo Rd, Lathrop", dated March 24, 2022. See attached workplan. ACCEPTED BY: =X L L EMPLOYEE #: DATE: ASSIGNED TO: L 5 EMPLOYEE #: DATE: Date Service Completed (if already completed): / Y r S rl�" SERVICE CODE: 1 P / E: 601 Fee Amount: �? Amount Paid `S'a, �-- Payment Date 3 -x:z- Payment Type � Invoice # C ck #�7 �`f yd �� Received By: EHD 48-02-025 �/.L4 LL SR FORM (Golden Rod) REVISED 11/17/2003 2022 >UNTY AL MENT