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Applications Will Be Proced When Submitted Properly Completed. Be Sur Sign The Application. <br /> • <br /> E APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APP,UCANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> �.IrENSE AND/OR REAL ESTATE INSPECTIONS <br /> 3TRATION POULTRY RANCHES AND KENNELS LIC. No. <br /> I• .BER MISCELLANEOUS SERVICFS Regist. No. <br /> QOIOr <br /> [Application Date May 18, 1988 Business/Name To A NORTH CAL CONSTRUCTION <br /> F Type Permit/Service Re nested: PLAN CHECK Appear On Permit <br /> 2 Applicant Name NORZ H CAL CONSTRUCTION <br /> Address P. 0. BOX 588, STOCKTON, CA 95201 <br /> Busme <br /> o. <br /> a Property Location/Address 429 W. LOCKEFORD eILODIe NCALIFORNIAS 95240 Emergency Telephone No. <br /> a Property Owner MA DEE KIDD <br /> -[Operator's Name MARDEE KIDD Address 429 W. LOCKEFORD LODI CA <br /> 1. FOOD ESTABLISHMENTSAddress 429 W. LOCKEFORD LODI CA <br /> Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> 11 ❑ MEAT MARKET <br /> FOOD PROCESSING PLANT ❑ COMMISSARY ❑ <br /> 11 ROADSIDE FOOD STAND 11ICE PLANT ❑ BAKERY <br /> ❑ CONFECTIONARY STORE ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> El VENDING MACHINES/No. of FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING — pp PY M V�O <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPADI( 1 <br /> ❑ MOBILE HOME PARK/No. of Spaces KK <br /> 3. WATER DUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA El WADING POOL ❑ NATURAL BAT <br /> E3NMEN�Pv\CtiS�S <br /> VECTOR CONTROL POULTRY FARM/Maximum No. of Birds 1 � \(BSER <br /> :ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method No. of Confining Cages <br /> Solid Waste Disposal Method <br /> Water Supply Source <br /> 6. CONSULTATION FEE SL(,L _ Animal Wte isposal Method <br /> 7. � <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Sample Title Company <br /> Sewage System Inspection ❑ Address <br /> Escrow No. Tele. No. <br /> Seller <br /> Telephone No. Seller Address <br /> Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X dzzoca� <br /> le �&^ <br /> Title ice.. <br /> Date 01 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ gNNUALLv PER UNIT ❑ PER SITE ❑ EACH ❑ Januaryt 8 Received B January 31 <br /> Y �' ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> DATE DATE AMOUNTDUED CHECKED <br /> FEE <br /> LESS -!l �/� lb�y N_anry� AMOUNT <br /> v v `+ zo � , <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER C1�1 `-fid ry V- !— `3.�✓ T (�JC� �1�•UU yyF{l� <br /> HER <br /> Re Dat ¢'s <br /> �— APPLICANT— Ft No Permit No. I95u ate <br /> RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PEgM1T/SERVICESMailed Deliveretl <br /> 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />