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� s <br /> SAN JOAQ0fItOUNTY ENVIRONMENTAL HEALTH ft*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR orD 4 ieq 15- <br /> OWNER/OPERATOR Madalena Moules CHECK If BILLING ADDRESS® <br /> FACILITY NAME Moules Property <br /> SITE ADDRESSI .1 N Jack Tone Road 95240 <br /> 13737 & J4ef umber Direction Street Name Lo City zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 12951 E. HarneLane <br /> Street Number Street a <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 Enr. APN# LAND USE APPLICATION# <br /> ( ) 063-250-27 <br /> PHONE#2 En. ©OS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E> . <br /> Neil O. Anderson &Associates Inc. 209 367-3701 <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 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,Syandar ,S,STATE and FEDERAL laws. //,�, <br /> APPLICANT'S SIGNATURE DATE: ((I <br /> PROPERTY I BUSINESs OWNER OPERATOR/MANAGER O OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTS'proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> TYPE OF SERVICE REQUESTED: Soil Suitability Study& Engineered Septic Design RECEIVED <br /> COMMENTS: e'1254ce,O 613e>" &100.4 <br /> ) •J <br /> -717-10e- - /!e f4. a JUN 0 5 2006 <br /> $AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> We HEALTH DEPARTMENT <br /> APPROVED BY: UC_ I V F, EMPLOYEE#: O Zf DATE: G e,fC <br /> ASSIGNEOTO: ESGOTro EMPLOYEE#: 54V; DATE: IvrcJ& <br /> Date Service Completed (H already completed): SERVICE CODE: `Z 7 P/E: <br /> Fee Amount: ._ Qf7 Amount Paid s . 6J Payment Date D b b U b <br /> Payment Type Invoice# Check# }! Received By: I C-'- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />