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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E��`U`l �� le� <br /> OWNER/ OPERATOR <br /> Craig & Sheri Watts CHECK If BILLING ADDRESS LaJ <br /> FACILITY NAME Watts Property <br /> SITE ADDRESS 16400N. Linn Rd. Lodi <br /> Street Number Dio�... Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P.O. Box 474 <br /> Street Number Street Name <br /> CITY Victor STATE CA ZIP 95253 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209 ) 368-2974 053-110-04 PA-1600201 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209 )369-0377 <br /> CITY Lodi STATE CA z"'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,Standards, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 0 —/0 —I (Q <br /> PROPERTY/BUSINESS OWNER 13 OPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT C0 NS UL-rp w'r <br /> I,fAPPLICANT is not the BILLING PARTY proof of authorization t0 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: C/ G It RECEIVED <br /> 2E QEi/l > 7- I OCT 10 2016 <br /> �'1 F Earn <br /> �'�2MiAl) err y� SAN JOAQUIN COUNTY <br /> (toll���om VIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Pmcwok, EMPLOYEE#: DATE: IIo I I IQ <br /> ASSIGNED TO: )t n l EMPLOYEE#: � 7.,DATE: I I l <br /> Date Service Completed (if already completed): SERVICE CODE: S'CI7�:J PIE: 2-teo <br /> Fee Amount: 7 v Amount Paid a 7L— Payment Date /0/10 16 <br /> Payment Type C Invoice# Check# G a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />