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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> Markus & Elizabeth Bokisch CHECK if BILLING AooR£S9 x❑ <br /> FAGLmrNAME Bokisch Vineyards <br /> SITE ADD 18909 & 19101 N. Atkins Rd. Lodi <br /> Street Number pirecgQq : Street Name Cit4 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 335 <br /> Street Number Street Name <br /> CITY Victor STATE CA zip 95253 <br /> PHONE X1 £"T APN tot LAND USE APPLICATION# <br /> (209 ) 614-4600 019-140-40 PA-0900094 <br /> PHONE#4T- BOS DISTRICT LOCATION CODE <br /> { I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racct? CHECK If BILLING ADDRESS <br /> SUSINESSNAMIE PHI:# EXT- <br /> Live Oak GeoEnvironmental <br /> 209 369-0375 <br /> HOME or MAILING ADDRESS FAX <br /> 407 W. oak St. ( ) <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 perform will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 'e"e� �' DATE: <br /> PROPk:R-M/DUStNFSS OWNERE3 OPERATOR I MANAGER 13 OTTrER AifTHORPLED AGENT© <br /> If APPLicANT is not the BILLING P,4RTY,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/ i /l assessment <br /> intonation to the SAN)oAQUQI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at it Juv i s <br /> provided to me or my representative E T <br /> TYPE OF SEFMCE REQUESTED! Review Soil Suitability/Nitrate Loading Stud F�B <br /> Geeealirrs: HSgN�DAQ1011V C <br /> SN�ALTHRo�RA <br /> ACCEPTEv BY' EMPLOYEE#: �? J/ DATE: 2-11( <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1` f ( 3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: QL <br /> Fee Amount (, er Amount Paid (O�s d-D Payment Date 1 <br /> Payment Type ✓ Invoice t1 Chuck 0 12 $ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 V1712D03 <br />