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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR 04�SZI�S" <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr Tom Gassner <br /> FACILITY NAME <br /> Ore- as ppedy <br /> SITE ADDRESS 11230 E Jahant Acampo 95220 <br /> Straet Number Direction Street Name Ci <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2919 Heritage Oak Way <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95242 <br /> PHONE#1 E". APN# LAND USE APPLICATION# <br /> ( ) 007-380-11 unassigned rA - 1'-73o S� 1 <br /> PHONE#2 E". BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> Nanny Rn,;ijlpk <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS FAX# <br /> 2 Industrial W (209)369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1-2- �1p o S <br /> PROPERTY/BUSINESS OWNERO OPERATOR/ ANAGER O OTHER AUTHORIZED AGENT OG� <br /> c <br /> 7jArrucanT is not the BILLING PARTY proof ojauthorization to sign is required Tine <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 /> TYPE OF SERVICE REQUESTED:Engineered Septic Design Plans Review PAYM <br /> COMMENTS: <br /> DEC 1 6 2005 <br /> r ) / 2tcNit 'N JCOUNTY <br /> ENVI VI N N NTAL <br /> R ENT <br /> APPROVED BY: p L( p A EMPLOYEE#: 6 3 Z i DATE: 12_ l V(Otz- <br /> ASSIGNED TO: " e N A EMPLOYEE#: .S3 (e G DATE: (2-If U(0t— <br /> Date Service Completed IN shaady completed): at SERVICE CODE: 5-22- PIE: q2 -U/ <br /> Fee Amount: 0 ( Amount Paid .yl ,U() Payment Date <br /> Payment Type Invoice# Check# /g.3 a�' Received By: 2e711— <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />