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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST# <br /> Swimming Pool & Spa in a Senior Living Facility so—m I ( <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> Oakmont Senior Living <br /> FACILITY NAME <br /> Oakmont Of Lodi <br /> SITE ADDRESS 2905 Reynolds Ranch ParkWay Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9240 Old Redwood Highway STE. 200 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Windsor CA 95492 <br /> PHONE#1 ExT• APN # LAND USE APPLICATION# <br /> ( 707 ) 535-3200 058-660-16 & 058-650-26 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 9240 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Joshua Toland CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Liquid Design Aquatic Consulting Co. 209 597-5277 <br /> HOME or MAILING ADDRESS FAX# <br /> 1852 West 1 lth St. ( 209 ) 831-9430 x <br /> CITY Tracy <br /> STATE CA ZIP 95376 <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, TATE and HE1"61and <br /> Digitally signed by Josh Toland <br /> OS <br /> C=US, E=josh@liquiddesignacc.com, O=Liquid Design Aquatic <br /> Consulting Company,OU= si n&C truction, CN=Josh Toland <br /> APPLICANT'S SIGNATURE: Date:202CIA.X�0.9:1 ZV201U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT © Pool Contractor <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 and at P s@> time it is <br /> provided to me or my representative. M�e <br /> TYPE OF SERVICE REQUESTED: Swimming Pool & Spa Plan Check All E� <br /> COMMENTS: <br /> 4 2010 <br /> We are pursuing a Swimming Pool SAN ,qutN Co <br /> & Spa Plan Check & Permit. HEALTH pFPgRTTAL <br /> UI TY <br /> MENT <br /> ACCEPTED BY: EMPLOYEE#: 6 �� DATE: q <br /> 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comp ted (if already completed): SERVI CODE: j Q P 1 E: � <br /> Fee Amount: Amount Paid Payment Date E�2/5 <br /> � . _ <br /> Payment Type " Invoice # Check # I` l (� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />