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COUNTY OF RIVERSIDE, DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies of a scaled plot plan drawn to county specifications required on the
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name Mailing Address
Q City State Zip Code Phone
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~ 'Property Address "City or Community 'Legal Description of Property (Lot, Parcel Map, Tract)
LU
Assessors Parcel No. Water Serving Property From Lot size
Signature of Applicant Date
'The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑ No ❑
Soils feasibility report required Yes ❑ No ❑
Detailed boring report required Yes ❑ No
Detailed contour plot required Yes ❑ No ❑
Comments:
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Soils or boring report by Date
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by Date
Approved
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Soils Map Page Soil Type Tract File No. Other
Number of Bedrooms
Septic Tank Size (gallons)
Rate Required
Type of System
New Addition Replacement
❑ ❑ ❑
Leach line sq. ft. of bottom area trench
Leach bed (sq- ft. of bottom area bed)
Seepage Pit Diameter
Number of Pits
Seepage Pit Depth B.I.
Total Depth of Pit
6':70 6' ❑'
Location of System
Additional Requirements,!`
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A permit is approved/denied for the design of a subsurface disposal system as indicated on the accompanied plot plan
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using the requirements set forth in Section B above. A building permit is necessary for the installation of the above
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designed system.
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Signature of Health Official uate
Receipt No.
District: Riverside ❑
DISTRIBUTION: WHITE - Office File
DOH SAN 122 (Rev 10/84)
. Issued By _____
Indio ❑ Hemet ❑
YELLOW - Applicant
Date
PINK - Building Dept. GOLDENROD - Pending File