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SAN JOAQU. :OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Mary Nordman CHECK if BILLING ADDRESS® <br /> FACILITY NAME Nordman Parcel <br /> SITE ADDRESS "49W- Woodbridge Rd. Woodbridge 95258 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3018 Seapull Lane <br /> Street Number treat Name <br /> CITY Stockton STATE CA Zip95219 <br /> PHONE#1 EXT. APN# LAND USE ADPLICI'nON# - <br /> (209 ) 476-0710 015-020-03 and -04 PA-04-105 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAx# <br /> 902 Industrial Way (209 )369-4228 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED LI s. <br /> APPLICANT'S SIGNATURE: i� DATE: 1/O L� <br /> PROPERTY/BUSINESS OWNER 12 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> CoMMENTs: Please review the attached Soil Suitability Study. The report review fee of$44 attached. <br /> If you h ve any questions, please do not hesitate call. Abby 2004 <br /> 4�7p� SAN JOAQUIN COUNN <br /> - h1V1RONMENTAL <br /> �CQa iJ� C`'z'` E EPARTMENT <br /> APPROVED BY: �)`i L, I � EMPLOYEE M C)3-Z/ DATE: 2/ 0 L <br /> ASSIGNED TO: d f � EMPLOYEE#: 0 1 Y DATE: 2.1 <br /> Date Service Completed (if already completed): SERVICE CODE: `5-•L- P I E: <br /> Fee Amount: - C, Amount Paid — Payment Date of D <br /> Payment Type ,✓ invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />