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SAN J(MQUDrCOUNTY ENVH2OONME+4TAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �/ qq3Erj <br /> OWNER/OPERATOR <br /> Verne Schultz CHECK((BILLING ADORESSO <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 31450 EastLone Tree Road Oakdale 95361 <br /> Street Number Street Name cityZi C <br /> HOME Or MAILING ADDRESS (if Different from She Address) 31146 East Lone Tree Road <br /> Street NYTEer Street Name <br /> CITY Oakdale STA CA <br /> zip 95361 <br /> PHONE#1 Em. APN# LAND USE APPLICATIONS <br /> ( 209) 847-0516 229-150-06 6- 0b 5) <br /> PHONE#L EAT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Verne Schultz CHECKif BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> 209 1 847-0516 <br /> HOME or MAILING ADDRESS FAX# <br /> 31146 East Lone Tree Road (209) 848-1301 <br /> CITY Oakdale STATE CA Z'P 95361 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:. _ 4Z �� DATE:)r <br /> PROPERTY/BUSINESS OWNER 13 O ERAT'OR AGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IjAPPUCavr is not the BILLING PARTY proof of authorization to 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. -y <br /> TYPE OF SERVICE REQUESTED: <br /> Soil Suitability Study& Engineered <br /> /Septic }Design RECENE <br /> COMMENTS: / �G " /e d CI '/HC - c-A* <br /> SA EN0')t 0EN fAl- <br /> MEt� <br /> HEALTH DEPART <br /> APPROVED BY: EMPLOYEE#: DATE: O <br /> ASSIGNED TO: � *S/D O EMPLOYEE#: O DATE: <br /> Date Service Completed (if already c mpleted): SERVICE CODE: 22 PIE: O <br /> Fee Amount: f)SO Amount Paid _I 'O , Payment Date � <br /> Payment Type � Invoice# Check# 7 Q Received By: �— <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />