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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME Dillon & Murphy <br />SERVICE REQUEST # <br />Almond Orchard <br />HOME or MAILING ADDRESS PO Box 2180 <br />5-pom rjJ <br />OWNER /OPERATOR <br />Sammy Heather Cox 2015 <br />STATE CA ZIP 95241 <br />and Trust <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />SITEADDRESS 15780 <br />N <br />Clements Road <br />DATE: j f 1 <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount. (� LJ <br />Amount Paid <br />PO Box 1592 <br />Payment Date <br />22 <br />Street Number <br /># <br />Street Name <br />CITY Linden <br />STATE CA ZIP 95236 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 916) 415-5236 <br />053-190-01 <br />PA -2200052 <br />PHONE #2 EXT. <br />BOS DISTRICT / J <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Joe Murphy p Y <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME Dillon & Murphy <br />COMMENTS: <br />PHONE# EXT. <br />209 334-6613 <br />HOME or MAILING ADDRESS PO Box 2180 <br />FAX # <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 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 FEDERAL laws. <br />APPLICANT'S SIGNATURYnote <br />07-19-2022 <br />DATE: <br />PROPERTY/BUSINESS OWNER❑ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Project Engineer <br />If APPLICANT is LLINGPARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: S fl ) Su ;1 �; i I I r yl C' <br />N ; t t,, fe Lo.- t,Ai M S t�C <br />Rf. V AWMENT <br />COMMENTS: <br />ECEtvE D <br />JUL 19 2022 <br />SAN JOAQUIN COUNTY <br />IRONMENTAL <br />HEENT <br />ACCEPTED BY: % <br />GJ <br />EMPLOYEE #: <br />DATE: j f 1 <br />ASSIGNED TO: F{ K <br />EMPLOYEE #: <br />DATE: ?//e,/ <br />as <br />Date Service Completed (if already completed): <br />SERVICE CODE: s a 3 <br />P I E: 6 0'� <br />Fee Amount. (� LJ <br />Amount Paid <br />Payment Date <br />22 <br />Payment TypeInvoice <br /># <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />