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-05-D'S-D'S 11 : 26 Mor 1 Civil Eng i neer i ng 20923-5044 P_.0: <br /> 06/30/2005 14.49 4648' t ' <br /> e+ ENVIR©NMU4TAL h .TH PAGE 02 <br /> SAN JO'01N COUNTY EN i ONMNTAL HEALTH DErA.RTI�IENT t <br /> SERVICE REQUEST <br /> FWayne <br /> hlasJrtess or Property FACJh�7YiD>I` SI:RVJCE JiEQLfJ:ST� - ; <br /> 5� 24' <br /> 1 OPERATOR <br /> Crai - Sandhill Development. <br /> FAcNAMEClements Oakrid e Estates LLC 1 0 L Lv U UI <br /> SrrEADDAFsS 18327 E. Hwy 88 <br /> r Clements _ <br /> HOME or kU LNG ADDRESS (tf Pifferer%t(mm Site Address) <br /> P.O. Box 1070 <br /> Crrr CA aa1M ZP 285 <br /> Woodbridge <br /> PHORE IM ,` fie► APN 9 Laud U APPUGATWH it i <br /> (209 ) 327-2222 019-220-26 00-5`(0�1 <br /> PKKEQ eKy. <br /> SOS cw R= Lo"TM con <br /> 09) 321-•6855 <br /> CONTRACTOR f SERVICE REQUESTOR <br /> ReOUESTOtt <br /> Jeff Morlan ttljaAsroAas� <br /> 8VSrrtE sNlu tr PWWI 6cr <br /> or an evil Engineerin 20 2 <br /> 23-1441 <br /> Floats or MAn a ADDRM FAIN <br /> 504 Broadway (209 ) 223-5044 <br /> Crr1r Jackson &TATE Zr <br /> 956/42 <br /> BEUXNG A02MM29nima. I, the undersigned property or business owner, operator or authorized agent of same, <br /> a4m*w1ed9e that all site aadlor project gwj6c EN%T*N M frAL HpAL-m DFrARTMWrbowiy ebugea associated wide this project or l <br /> activity will be billed to me or my business as identified on dais lbw <br /> I also eenily d at I have prepamd ft application sad that tba work to be performed wilI be done in accordance with all SAN JOAQM <br /> Com Ordnrorree Cedes,Staedurds,STATE and FWMAL laws- i <br /> APPLICAN'T'S SIGNATURE: DATE: <br /> rRonmTvi$VsmmChvmRO OrMATtut/&UNAC= Q ornmADmm=Aotta❑ <br /> IfAmicAw it not the, proof of awthoriza&m to sign is rtqulrned itrte <br /> TO RZtJA0.nMBMA31M.When applicable,I,the ewtaer or operator of the property located at the <br /> above site address; hereby authorize the release of,any and aR reruns, geotcclmicsl data and/or enviro>nacatal/aite assessment <br /> information to the SAN JOAQUtH COUNTY E,NMONMEWrAL Hear TH DEPARTMENT as soon as it is available and at the same time it is <br /> pryvided to me or my representative. 2A-,(MF- <br /> TYPE <br /> E <br /> TYPE Or SERVICE PSWESm: t�r c�� r d c,-)A-9-re POL,4, J GFt E C*e-- of <br /> RECE <br /> COMMEN": FiA <br /> „ es&e �I AA�O�1Jv . JUL 5 2005 <br /> r sy�� �0 . cOUN <br /> SAN JOAQUIN <br /> EtSvV1 OF-P STM <br /> HEM3 1 t) <br /> Acc"TEu tar: r�11r r 2i4 <br /> EMPLOYEEC <br /> p 3 Z f -Date: 7 S 0 S- <br /> Ass: rQ .N Emp oar;#F: S3 6 DATE: `7 s OS <br /> Date Service Completed (E already completed): 31"M COVE: <br /> Foe Amount: £�(Q O a7 Arnount fold * I FL .0'p payment Data -7 C <br /> Payment Type Mvodce# Check aT Received By. <br /> PHO 48.02-025 SR FORM(Golden Rod) <br /> nc�n CCft 44I47r1MY1 <br /> F <br /> y <br /> 1 <br />