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SAN JOAQUIN ( NTY ENVHIONMENTAL HEALTH I ATMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />swimming pool/spa for new apartments <br />O_ <br />BUSINESS NAME <br />Eagle Pools, Inc. contact: Mike Nantze <br />DATE: _/7 -(fl <br />OWNER/ OPERATOR <br />EXT. <br />995-5288 <br />Gateway Crossing Tracy, LLP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />489-8009 <br />Gatewax Crossing 2 Apartments <br />STATE Ca <br />SITE ADDRESS 36SP <br />0Slreet <br />Amount Pa <br />Grantlines2FName <br />Payment Date <br />Tracy <br />95304 <br />Number <br />Direction <br />Race ed By: <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />3140 <br />��/ <br />`/t/iTlame <br />Peacekeepers{ree <br />Street Number <br />CITY <br />STATE ZIP <br />McClellan <br />Ca 95652 <br />PHONE#1 ExT. <br />APM# <br />LAND USE APPLICATION# <br />( ) <br />q'- 60 <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />aU-D <br />v :�!:) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Y \ I � \( I K- / <br />I <br />—1 <br />A'v L,�_ <br />COMMENTS: plans are being submitted to plan check plans for a brand new inground guniteT�6 40-"' .7), <br />TMFTtTT <br />CHECK if BILLING ADDRESS <br />O_ <br />BUSINESS NAME <br />Eagle Pools, Inc. contact: Mike Nantze <br />DATE: _/7 -(fl <br />PHONE # <br />EXT. <br />995-5288 <br />HOME or MAILING ADDRESS 3329F916 <br />C el <br />DATE _I 7-1k _/& <br />c ) <br />489-8009 <br />CITY Carmichael <br />STATE Ca <br />ZIP 95608 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned properly 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 JOAQUTN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL <br />laws. <br />APPLICANT'S SIGNATURE: // U l �l4 �� DATE: &qk /Z01 r' <br />—r <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />IfAPPLICANT is not theB7LL/NG PARTY. proof ofauthorimlion to sigh is reVired Title pQ��''90� <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the prope <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environments]% <br />information to the SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tj?sF <br />provided to me or my representative. Jrt– I`u <br />TYPE OF SERVICE REQUESTED: &A <br />g F �DAp 18 <br />COMMENTS: plans are being submitted to plan check plans for a brand new inground guniteT�6 40-"' .7), <br />TMFTtTT <br />ACCEPTED BY: �� <br />EMPLOYEE#: <br />DATE: _/7 -(fl <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE _I 7-1k _/& <br />Date Service Completed (if already completed): <br />SERVICE CODE: SZ <br />PIE: 3(eo / <br />Fee Amount: �p� <br />Amount Pa <br />D D <br />Payment Date <br />Payment Type G"` tL <br />Invoice # <br />Check #3 <br />Race ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />