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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br /> 0 3 Lo 2 3 1 <br />Type of Business or Property <br />HOA ,r 1, <br />FACILITY ID # 000 _24 <br />SERVICE REQUEST # <br />,C.Rtg <br />OWNER / OPERATOR <br />North Point Villas CHECK if BILLING ADDRESS <br />FACILITY NAME North Point Villas <br />SITE ADDRESS <br />3634 Street Number Direction <br />Mill Springs Dr <br />Street Name <br />Stockton <br />City <br />95219 <br />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. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Er-. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Hugo Varo CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Burketts Pool Plastering <br />PHONE # <br />( ) <br />EXT. <br />209-624-2918 <br />HOME or MAILING ADDRESS <br />600 N Frontage Rd <br />FAX # <br />( ) <br />CITY Ripon STATE CA ZIP 95366 <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 SIGNATURE: DATE: <br />5/11/21 <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MANAGER El OTHER AUTHORIZED AGENT El Contractor <br />If APPLICANT is not the BILLING 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. <br />TYPE OF SERVICE REQUESTED: Too 1 04 lahlfr l ITO I iiii 'AZ-4, ck-i,fr ) <br />COMMENTS: <br />414) 1' <br />%944c/0 <br />/2 <br />4 <br />202/ <br />1/44111/kCitiN C 71.7 9 iD A/4,140(i4/71, <br />ACCEPTED BY: LA tit ra ,c, • EMPLOYEE #: gIS i2-DATE: <br />ASSIGNED TO: V IsalciA ID. EMPLOYEE #: (pgi ' ,3 <br />s <br />S--/ <br />- 2_121 <br />DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 52......, P <br />Fee Amount. 19?.. VO Amount Pai /SD? .00 Payment Date <br />Payment Type 11' ,R e.), Invoice # Check # Receive By:(.974---=' /25-2 Z.... <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />ottcd <br />SR FORM (Golden Rod)