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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> San Joaquin County <br /> OWNER/OPERATOR <br /> Eastern San Joaquin Groundwater Authority CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ESJ Subbasin Interconnected Surface Water Monitoring Wells <br /> SITE ADDRESS d73�0 N NPy,/ t-iope <br /> multiple-see maps <br /> treet Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1810 East Hazelton Ave Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95205 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 953-7460 D of a 10 3 Z) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Leslie Dumas/Joe Zilles CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Woodard&Curran/Weinfelder 916 999-8700 <br /> HOME or MAILING ADDRESS FAX# <br /> 801 T Street ( ) <br /> CITY Sacramento STATE CA ZIP 95811 <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, STATE and FEDERAL laws- <br /> APPLICANT'S SIGNATURE: J"J' �^ a° DATE: 9/2/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <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�l at he same time it is <br /> provided to me or my representative. /4 <br /> TYPE OF SERVICE REQUESTED: Well construction permit review and approval [:O <br /> COMMENTS: VCtj <br /> Construction of shallow(-50 ft deep)monitoring wells for monitoring impacts to interconnected surface waters . SA/V 1/01/0,4O ?022 <br /> y�AC LEN V/�ROHM CO <br /> 7 '� iV S 1�C '/` /�' UITTI( WS"-!� �r�N�Y <br /> Nr� <br /> -z732ozo & , N&iv morE s9064s7f- <br /> ACCEPTED BY: Steven Shlh EMPLOYEEM DATE: 9/2/2022 <br /> ASSIGNED TO: Steven Shlh EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P i E: 4301 <br /> Fee Amount: 312 1 <br /> Amount Paid Payment Date <br /> Payment Type credit Invoice# 149295969 Check# T l ZgS�G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />