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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />KO of � Re, <br />Ay <br />SERVICE REQUEST # <br />Bare land with Residence <br />PHONE# EXT. <br /><71�� <br />M1 4 Y 13 2022 <br />209)334-6613 <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />OWNER / OPERATOR <br />PO Box 2180 <br />Dave and Cheryl Gallagher <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />STATE CA ZIP 95241 <br />SITEADDRESS 13294 <br />E. <br />Harney Lane <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />DATE: <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P 1 E: a (OC)3 <br />Fee Amount: 7 3 <br />Street Number <br />3 o <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(209) 607-9444 <br />063-260-16 <br />PHONE #2 EXT. <br />BOS DISTRICT/ <br />LOCATION CODE <br />( ) <br />L <br />!(� <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CoY1 �f m t n 'loll <br />KO of � Re, <br />Ay <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Dillon &Murphy <br />PHONE# EXT. <br />M1 4 Y 13 2022 <br />209)334-6613 <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />FAX # <br />PO Box 2180 <br />ENVIRONMENTAL <br />(209t334-0723 <br />CITY Lodi <br />STATE CA ZIP 95241 <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 DEPARTMEN'r hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 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 FI:DFRAL. laws. <br />APPLICANT'S SIGNATURE: <br />DATE: May 10, 2022 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AuTHORIZEDAGENT® Project Engineer <br />IfAPPL1CAN7' is not the B11 LING 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. r%AXZIU13r—ILrT <br />TYPE OF SERVICE REQUESTED: S U f t H<e 3 S v�s U f �ttGe <br />CoY1 �f m t n 'loll <br />KO of � Re, <br />Ay <br />COMMENTS: <br />M1 4 Y 13 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Gw <br />EMPLOYEE #: <br />DATE: $/I3 .72 <br />ASSIGNED TO: 1- ✓c h k la <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Sa 3 <br />P 1 E: a (OC)3 <br />Fee Amount: 7 3 <br />Amount Paid <br />3 o <br />Payment Date � / 7 ,2.,_ <br />Payment Type <br />Invoice # <br />Check # 76 <br />z <br />Received By: <br />EHD 48-02-025 SR ORM (Golden Rod) <br />REVISED 11/17/2003 <br />