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APPLICATION FOR PERMIT >' ~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1555 NEWPORT AVE. city STOC KT Size PM Owner's NameJOHN MYRTAKIS Address 1600 SUNRISE #4,MODESTO Phone 1-576-2835 Contra ctorVETTER PLBG. CO. FAT S_ 1035 S. AURORA ST�,License No. 202228 Phone 463-1706 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE --� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair'.Work bone ❑ Type of Pump W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ' Filler Material (Below 501- + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is + available within 200 feet.) Installation will serve: Residence_ Commercial.'— Other T Number of living units: Number of bedrooms--,--_- Character edrooms '• Character of soil to a depth of 3 feet: i ~` Water table depth O SEPTIC TANK ElType/Mfg ` Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ ' , i Method of Disposal Distance to nearest: Well Foundation Property Line , LEACHING LINE ❑ No. & Length of lines , l Total length/sizeµ f,. FILTER. BED ❑ Distance to nearest: Well Foundation f Property Line j SEEPAGE PITS ❑ Depth Size # —'Number SUMPS ❑ Distance to nearest: ! Wel! =-Foundatio_n - Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. k 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 shall not employ any person in such manner as to become-subject°to-workman's-compensation-laws of"Califoniiia"'-Cotitiactor's hiring or sub-contracting signature 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 compensa- tion laws of California." The applicantt call for all squired i spe s: Complete drawing on reverse side. Signed Title: PRESIDENT Date: 3/20/87 FOR DEPART ENT USE ONLY Application Accepted by Date Area /J 2—_.__ Pit or Grout Inspection by Date 1,�yA� Final Inspection by ` Date }}}�� �� If Additional Comments: _�uCom, 661b .4" �zze;� ❑ Stk' 466-6781 El Lodi 336°9`_3621 ❑ Manteca 823-7104 ❑Aracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/5ery1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T FEE INFO AMOUNT DUE AMOUNT REMITTED GK# RECEIVED BY DATE (�PERMIT"NO. + EH 13-24 MEV.1/a51 3s rwr, EH 14-28 J tJ lJ ��CCJl