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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � cx�7�(- -,(— <br /> OWNER/OPERATOR Ron McManis CHECK if BILLING ADDRESS ID <br /> FACILITY NAME North Forty Vineyards, LLC <br /> SITE ADDRESS 19750 N. Lower Sacramento Rd. Acampo 95220 <br /> Street Number Direction I Street N me City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18700 E. River Rd. <br /> Street Number Street Name <br /> CITY Ripon STATE Zip <br /> CA 95366 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 649-6821 013-180-50, -51, -52, -53 PA-1500048 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 /> c'TY Lodi STATE CA Z'P 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 tot the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> —1 /7APPLICANT'S SIGNATURE: �7 DATE: / <br /> PROPERTY/BUSINESS OWNERS O BATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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. YMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study RECEIVED <br /> COMMENTS: JUL Q $ 2015 <br /> S"JOAQUIN COUNTY <br /> SCGTZ� OLMHarPRNTAL <br /> RTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:Cif-16" l <br /> ASSIGNED TO: 1: Cy 1 I " EMPLOYEE#: GJU a� DATE: --7-/&"0 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid (J 0 U Payment Date -7 N 1 cj <br /> Payment Type ��e( (� Invoice# Check# ', q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />