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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property Ti FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />Britta & Kevin Golding <br />FACILITY NAME Golding Property <br />SITE ADDRESS 9,422 S. Priest Rd. <br />HOME or MAILING ADDRESS (If Different frorn Site Address) <br />st <br />CITY South Lake Tahoe <br />PHONE til EXT. APN # <br />( 9251 223-7380 193-220-72 <br />PHONE #2 EXT. <br />l ) <br />CHECK if 8.11 LING ADDRESS <br />French Camp 1 95231 <br />- Clty <br />P.O. Box 18019 <br />Street Name <br />STATE CA ZIP 95651 <br />LAND USE APPLICATION # <br />BOS DISTRICT II LOCATION CODE <br />r, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />BUSINESS NAME PHONE# <br />Live Oak GeoEnvironmental 209 <br />HOME Or MAILING ADDRESS FAx # <br />407 W. Oak St. , <br />CHECK if BILLING ADDRESS 0 <br />ExT. <br />IL CITY Lodi STATE CA ZIP 95240 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknoN ledge 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />CC!t. NTY Ordinance Codes, Standards. STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: . <br />L�[}\ DATE: Z-�i • �G?Z� <br />PROPF.RTI i BUSINESS O" NE� OPERATOR / MANAGER THER AUTHORIZED AGENT ❑ <br />ifAPPLIGrNT is nos the BILLLNG 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 artabe• le time it is <br />Reepro%ided to me or my representative. 9Y ,1 *1 . <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/NitreatA I_rindinn Rturiv VFn <br />GENTS: <br />AUG 24 2022 <br />A N OROIV OOLJNTY <br />H EALTH D�pgRTMENT <br />ACCEPTED BY: <br />� !— <br />EMPLOYEE #: <br />DATE: U <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: (/ <br />Date Servica Completed (H already completed): <br />SERVICE CODE: 3 3 <br />PIE: a J� <br />Fee Amount: <br />-4 ( L <br />Amount Pal 6 Z/ --f <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # ! C�� 33 r <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />