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SAN JOAQU11v COUNTY ENVIRONMENTAL HEALTh.JEPARTM SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Bare land with Residence OWNER/OPERATOR Dave and Cheryl Gallagher CHECK if BILLING ADDRESS FACILITY NAME SITEADDRESS 13294 E. Harney Lane LodiF 95:2�40 Street Number Direction Street Name CityZde HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 Exr• APN# LAND USE APPLICATION# (209 ) 607-9444 063-260-16 PHONE#2 EXT. BOS DISTRICT t ) LOCATIONCODE r CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# Exr. 209)334-6613 HOME or MAILING ADDRESS FAX# PO Box 2180 ( 2091334-0723 CITY Lodi STATE CA zip 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENv1RONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: May 10, 2022 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Engineer If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. i� TYPE OF SERVICE REQUESTED: -S fTi(e- 3 Su�jUt �lcC CoYl imfn��oYt R� o(� Re COMMENTS: MAY 13 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: �J �v EMPLOYEE#: DATE: ASSIGNED TO: Fy t7/ki k EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: SoZ 3 P I E: a(x(73 Fee Amount: �3DLJ I Amount Paid 3 Q Payment Date 3 �L Payment Type k Invoice# Check# —7/& Z Received By: EHD 48-02-025 SR'FORM(Golden Rod) REVISED 11/17/2003