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SAN JOAQuiN COUNTY ENVIRONMENr7'AL HEALTH DEPARIMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �((SSJERVICE RR�-EQUE /r <br /> Single-FamilyResidential 7�'ncJ�� � <br /> OWNER/OPERATOR <br /> Stockton Main Venture Group, LLC CN fffiu-mc; oo <br /> FAaLITY NA <br /> figurian Village Unit 2 <br /> SIrEApnockg 92 rJ1VCl(, <br /> J Vv Ln Stockton <br /> s[N er ee[Nama C' <br /> HONE or MAILING ADDRESS (if Different from Site Address) 6464 East Live Oak Road <br /> Sveet NumMf Name <br /> CITY STATE LP <br /> Lodi CA 95240 <br /> PHWCl APMs16q—ft 195- LAND UseAPPucATroNf <br /> (209) 463-1869 To be deberf---- <br /> PHONE SI W. 15 <br /> 1 (209) 9-8763 � -f10-1O BOSDISTwcT .2- <br /> tocanoNCooe <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REouEsTOR <br /> Cne tF SILLNIG Aoola:ss® <br /> BusrNEHSNAME PHONE# - En. <br /> Stockton Main Venture Group, LLC (209) 463-1869 <br /> HOME of MAILING ADDRESS <br /> 6464 East Live Oak Road (2p ) <br /> CITY Lodi STATE ZIP <br /> an■rvn AC NOWLEDGEMEN'T: 1,the undersigned property or business owner, operator of authorized agent of same, <br /> acknowledge that all site and/or project specific ENMONMaNrAL HEALER DEPARTNIENi hourly charges associated with this project <br /> of 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;Standm'd�s,STALE and FEDERAL laws. <br /> APPLICANTS SIGNATURE:_ DALE: 7 I <br /> 1 k� <br /> PROPYAIY/BUSIIYTSSOWNLR VJ OPERATOR/:HAtiAG ❑ OIrrRAUIHORITED AG[NT❑ M6.MOC eA ONJ it <br /> IJAPPIICLv7 is not the BffzwGPJlR7T.proof ajauthorizakon to sign is required Till, <br /> AUJ'HORIZAFION ]JO RELEASE INFORMATION: Ulm applicable,L 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 eavironmexual/site assessment <br /> information to the SAN JOAQUIN COUNIY FNVIRONMENIAL HEAL THDEPARrmE•NT as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> TYPE OF SERACE REQUESTED: Surface and Subsurface Contamination Re oxt R viIDEPAR <br /> T <br /> 6 , oco7 <br /> o "'""-� VSAN JNTY <br /> ENLHEALENT <br /> ACCEPTEDErr Lr�� EMPLOYEE#:D fLSTE 117 <br /> ASSIGNED TO. _, / EMPLOYEE#: tfATE: <br /> S/0'7 <br /> Date Service Compketed (N already completed): SERME CODE: 3t PIE <br /> 2(oV3 <br /> Fee Amount: U 1 cl(r, Amount Paid ' ll Payment Date U 3 0, <br /> Payment Type `/ Invoke* Check 1V 0 96 1 Recelmd By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISEDED111111f17P2003 <br />