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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Jacob Hodge SERVICE REQUEST #--77J Winery DATE: / �Z PHONE# ExT. C.T. Brayton & Sons, Inc. OWNER / OPERATOR 209 838-7388 The Wine Group CHECK If BILLING ADDRESS® FACILITY NAME The Wine Group 1804 Jackson Ave SITE ADDRESS E Highway 120 STATE CA ZIP 95320 Ripon 95366 Rec Ived By: IGG39 Street Number DI rection Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT• (209 ) APN # LAND USE APPLICATION # 993-1905 PHONEY ExT• ( ) BOS DISTRICT11 CATION CODE 13 ef F CONTRACTOR / SERVICE REQUESTOR �� REQUESTOR Jacob Hodge CHECK If BILLING ADDRE 4 BUSINESS NAME DATE: / �Z PHONE# ExT. C.T. Brayton & Sons, Inc. DATE: 9// 7 . 209 838-7388 HOME or MAILING ADDRESS FAX # 1804 Jackson Ave Amount Paid /S- d� ( ) CITY Escalon STATE CA ZIP 95320 I 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: DATE: S�I7%Z PROPERTY/ BUSINESS OWNER❑ tl OPERA OR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor IfAPPLICANT 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 assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tiyyf it is provided to me or my representative. A Y TYPE OF SERVICE REQUESTED: COMMENTS: AN k EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 0�1 :HT Inspection of the Force Main Sanitary Sewer Line for Proposed new Building connection to existing S M. Ugr; fy con nec bion 4b Pu >-p St4i-;brt/t, Fig s� � inn, lie ►� by oti.1 y'* oHl'vc y�FA�hr M ACCEPTED BY: L��!_ EMPLOYEE #: DATE: / �Z ASSIGNED TO: A / EMPLOYEE #: DATE: 9// 7 . Date Service Completed (if already Completed: SERVICE CODE: �� / P i E: Napa Fee Amount: Amount Paid /S- d� Payment Date s 7 Payment Type11� Invoice # Check # ��37,1 Rec Ived By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 0�1 :HT