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FACILITY ID# <br />Owner I Operator <br />Pete Murdaca <br />Facility Name Pietro's <br />Site Address LodiRocky Lane <br />city <br />City StateLodi CA <br />APN#Land Use Application #Ext, <br />058-66-013 <br />Email BOS District Location CodeExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Chris Canney <br />Business Name Ext.Arcanum Architecture <br />Home or Mailing Address 329 Bryant St, Suite 3C <br />State CACity San Francisco Zip 94107 <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: New restaurant plan check <br />Comments: Construction of a new full service restaurant and bar. <br />Vidal Pedraza 6213Employee #:Date:Accepted By: <br />9838 3-19-24Francisco Ruiz Employee #:Date:Assigned to: <br />Service Code:Date Service Completed (if already completed):523 <br />486 Payment DateAmount PaidFee Amount: <br />Payment Type Invoice # <br />payment 178200844 <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />Type of Business or Property <br />Full Service Restaurant <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />95240 <br />Zip Code <br />282 <br />Street Number Direction <br />Home or Mailing Address (if Different from site Address) <br />Street Name <br />317 <br />Street Number <br />Phone#1 <br />( ) <br />BILLING ACKNOWLEDGEMENT: I, 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 or activity <br />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 />Cfwck# <br />Phone # <br />( 415)357-4415 <br />Fax# <br />( )________ <br />Email chris@arcanumarchitecture.com <br />Check if Billing Address D <br />Phone #2 <br />() <br />Check if Billing Address D <br />P/E: 1601 <br />Received By: <br />®vNed <br />MAR 20^ <br />3-19-24 <br />_____ ________ _____________ Date: /’/fi/_______ <br />Property/Business Owner * . Operator I m/nager-0 Other Authorized Agent 13 TT <br />If Applicant is not the Billing Party, proof of authorization to sign is required T tile <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />San Joaquin County Environmental Health Department as soon as it is available and at the same time it is provided to me or my <br />representative. <br />Kettleman Lane <br />Street Name__________ <br />ZlP 95420