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"cul" SAN JOAQUIN COUNTY <br />2r : -c.:r : •.Z <br />y; ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�q•.-=;::.�;:P Office: (209) 468-3420 Fax: (209) 464-0138 Web: vvww.sjgov.org/ehd <br />�fFOR <br />Request for Compliance Date Extension <br />LOCATION: CITY: <br />PROPERTY OWNER NAME: <br />List tasks needed to correct all violations and provide a date the task will be completed. In the comments section, provide specific <br />information describing the task: type of unsafe condition, type of pre -permit activity (i.e. preparation of plans, asbestos survey/utility <br />disconnect for demolition), type of permit needed (i.e. local building permit, well or septic permit, State Housing and Community <br />Development permit , etc. Use additional paper, if needed. <br />COMPLIANCE TASK <br />DATE <br />COMMENTS <br />Property/Unsafe Condition Cleanup <br />Property/Unsafe Condition Securement <br />Pre -Permit Activities <br />Obtain all Required Permits <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Repair/Demo Task <br />Final all Required Permits <br />OWNER STATEMENT: I am proposing the above noted compliance dates to perform each securement, <br />cleanup, repair or demolition task to correct the violations cited in the Notice and Order to Abate. I understand <br />that I am required to obtain any required permits for all repair or demolition work. I understand that the EHD <br />charges an hourly rate for all time spent on this enforcement case. I further understand that failure to comply <br />with these compliance dates may result in further enforcement or abatement actions. <br />SIGNATURE OF PROPERTY OWNER/AUTHORIZED AGENT PHONE <br />TITLE DATE <br />(EHD USE ONLY) <br />NOTICE AND ORDER TO ABATE DATE: <br />PR#: <br />APPROVED BY: <br />DATE: <br />EHD 13- 10/22/13 Request for Compliance Date Extension <br />