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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR n <br /> Dennis and Nancy Souza CHECK If BILLING ADDRESSL,i,I <br /> FACILITY NAME <br /> SITE ADDRESS 27420 S Walnut Ct. <br /> Tracy 95340 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 )969-5754 d q?3 D,-7, <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) c�C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Don Chesney, PE CHECK If BILLING ADDRESS <br /> BUSINESS NAME Chesney Consulting PHOExT. <br /> O9 402-1652 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 3794 ( ) <br /> CITY Turlock STATE CA ZIP 95381 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site anld/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 a lication and that th rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T 'rI and FE.D L l a <br /> APPLICANT'S SIGNATURE: znz DATE: —�Z —2p <br /> PROPERTY/BUSINESS OWNER® OPERATOR/M, 'AGER ❑ THFR AUTIAORIZFD AGENT❑ <br /> 1J'APPLK A:N7 is not the BILi.,LVCi PARTY proof of autho zation 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 HEALTIi DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: Plan Check for O.W.T.S. Design EC <br /> COMMENTS: JU <br /> s,�Jo� <br /> E QU/N <br /> H HIoZ�MAL <br /> ENT <br /> ACCEPTED BY: —� 1� EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <-J3 PIE: Ll <br /> Fee Amount: 3 U Amount Paid eff Payment Date C /z 2� <br /> Payment Type 2 C Invoice# Check# 56IF 12d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />