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I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinarxjes, state laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, I shelf not <br />employ any person in such manner as to become subject to workman's compensation taws of California." Contractors hiring or sub-contracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br />cornpensa- <br />tion laws of California." <br />The applicanj must calor all wired inspections. Complete drawing on reverse side. <br />Signed x r 15�.,'i L . �r ,` r^ , <br />g �. Title: -- T Date: <br />1✓ / FOR DEPARTMENT USE ONLY <br />Application Accepted byArea <br />Date <br />Pit or Grout Inspection by - D1 _ _ Final Inspection by Date <br />r" <br />Additional Comments: -( hf ;.�®r ), Uu.�-% <br />---._ <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 it Tracy % <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,rCA 95201FEE <br />INFO AMOUNT DUE AMOUNT REMITTED `-CASH �RECEIVEO 8Y DATE PERMIVNO. <br />EN 13-i4 1AEV. n 51 <br />EN 14-25 <br />-4`j i <br />RE <br />