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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 ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's xipittiture hrlifios'the`following:-"I-certify that in the performance of the work for which this permit is issued, I shall not <br />employ any person In su�hranner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies the following I'ce Ify that In the rfo�nfarics of the work for which this permit is issued, I shall employ <br />_ p P Y Persons subject to workman's contponsa- <br />tion laws of California."- � � % , <br />The applicant r u call forallVie nspactions Complete drawing on reversesid . <br />Signed K_ — --__ Title:—__--•_`�. <br />-- Date: <br />FOR EPARTMENT USE ONLY <br />Application Accepted hyt _ <br />Date�� <br />t-• : ���Area <br />Pit or <br />Additional CommentsFinal Inspection by _ <br />-- — Q{ tic Date ,/Q__��( <br />: 1 <br />U Stk 466.6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ------" - <br />Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED CK i - " <br />INFO �'%— CASH RECEIVED 6Y DATE PERMIT -NO. <br />EH a}21 (REV. I/N5� ! fl <br />Ell 14•20 <br />JJ/ <br />. <br />.I <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL I4EALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />i Telephone (209) 466-6781 <br />PERMIT EXPIRES VYEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application <br />I made in compliance with San Joaquin County Ordinance No. 549 for sewage No. 1862 <br />is <br />or for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />1. .. <br />Job Address City��'^'Y� <br />; Lot Size PM <br />— <br />r <br />Owner's Namu Address Lob, 0—z <br />._ . .-Phone <br />- <br />.`N Contract `• Address•_ 76 <br />f �/ <br />{� <br />ti <br />