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SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> j�R(D(DL'to �2c� <br /> OWNER I OPERATOR <br /> David & Sherrie Van Vliet CHECK if BILLING ADDRESS® <br /> FACILITY NAME Van Vliet Property <br /> SITE ADDRESS 17050 E. Lone Tree Rd. Ripon 795320 <br /> Street Number Dire ion Street N nw i Zip <br /> HOME or MAILING ADDRESS (if Different from Site Address) P.O. BOX 720 <br /> Street Number N m <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 969-1212 203-210-05 <br /> PHONE#2 EXT. BOS DISTRICT LOCALl TIOJIfDE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnviron mental 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# PAYMENT <br /> 407 W. Oak St. ( 1 RECEIVED <br /> CITY Lodi STATE CA Z'P 95240 MAY 17 2023 <br /> BILLING AC"OWLEDGEMENV"T: 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 pro cct'AN JOAQUIN <br /> OIRONMENOUNTY <br /> or activity will be billed to me or my business as identified on this form. HEALTH DEPARTMEW <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 f C- DATE• - `i - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER ALmioRIz.F.DAGENT❑ CE SZ/LTAr,-,T <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 ENVIRONM`NTAI.IIF LTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: <br /> cl�ym-sC L /moo/� <br /> ACCEPTED BY: Seryl ( EMPLOYEE#: DATE: <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): ERVICE CODE: C 2�? !Ej 0 f� <br /> Fee Amount: =jco Amount Paid Payment Date <br /> Payment Typel� q <br /> nvoice# C # Received By: <br /> EHD 48-02-025 1(A/14>�/3 SR FORM(Golden Rod) <br /> REVISED 11,17/2003 <br />