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SAN 30AQUl� :,COUNTY ENVIRONMENTAL HEALTH.>ZPARTMENT <br /> SERVICE REQUEST <br /> . <br /> Type of Business or Property FACILITY Ill:# ;SERVICI R1=Qt1EST.# <br /> OWNER l OPERATOR Geary Goss, General Manager CHECK if BILLING A°DRESSO <br /> FACRITYNAME Stockton Golf and Country Club <br /> WE ADDRESS 3800 Country Club Blvd. Stockton 95204 <br /> ode <br /> StreetNumber on ame C I C <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number S N <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USI:APPLICATION# <br /> (209) 466-4313 Engineered Septic System <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQIIESTOR David Welch CHECK if BILLING ADDRESS MJ <br /> BUSINESS NAME PHONE# EXT' <br /> Neil G. Anderson &Associates Inc. 209 1 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA zip 95240 <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 HEALyn 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, and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENfO` <br /> If APPLICANT is not the BILLING PARTS.proof of authorization to sign is requireW Ti,le <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 the same time it is <br /> provided to me or my representative. <br /> i TYPE OF SERVICE REQUESTED: � u t G✓� f i�}� �A� r <br /> COMMENTS: Please review the engineered eptic s m rawing and reports.. /A report review feRECEE Ep <br /> o $465 is ed. 74fVeY' <br /> D !�� 7/ 6 �orvt ���rr�s 5 Ju <br /> 7 u 2fla4 . <br /> �� <br /> AN,�DAQXJ't ENTAL <br /> APPROVED BY: <br /> "E MPLOYEE#: . DAT.E:'' I ETI <br /> ASSIGNED TO " EMPLOYEE DATE: . <br /> Date Service Compieted (if already completed): Ssylci C,3n > . t f <br /> Fee Amount: Amount Paid.r ..��(� (TZ� Payment Date, J( (b If <br /> Payment Type <br /> # Ch <br /> '.Invoice eck# is�f Received'By: �. .: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> I <br />