PLBG (0108-146) + BLCK (05287) + SFD (05283)51980 Avenida Martinez
0108-146
05287
05283
LICENSED CONTRACTOR DECLARATION r
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic _Class Exp. Date
gA
4(XZt
Date ' r*' Signature of Contractor
wi.
,.....,_._--.-------OWNER=BUIL"t DECLARA ON
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) j am exempt under Section , B&P.C. for this reason
Date i, Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( J? I have and will maintain workers' compensation insurance, as required by
.Se_ction 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver Policy No.
WTFOR.D UNDERV 76WV"M
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject tb the orkers' compensation provisions of Section 37001of th Labor
Code I. s JI o hwith comply wit Ab , provusi • ns ,` 6a. O
Date: Applicant
Warning:-Failuree io secure Workers' Comp nsatlon coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on : bis
application. G
1. Each person upon whose behalf this application is made & each persdnat
whose request and for whose be•pefit-work its performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shalli indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of th'i¢ City to ter on
the above-mentioned property for inspecti pur ses ,i
Signature- (Owner/Agent) Date t
BIJI{LDING`PERMIT PERMT/i
. .
DATE VALUATION LOT 0113E I416 TRACT
QM3*K 839&W
JOB SITE *
APN
ADDRESS
St-**Avz=AMAA' i?t
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
8AMIJEL I V.ARW
1 ON I APPLIANCE REP"
y.
519W AVIUMA WRT W
72773 P"ON RD,
LA U12x:ACA53
THOUSAND PALS CA 9'2276
A,
(760}343-2294 CBL*
USE OF PERMIT
P`I.L11+ NCi
IN3?ALt, 30 IaAL HOT WATXR HEA (R9PLAC1rMLrNT)
r
i
r
r,-VAIAIA'1'ION' 39!.01 L,3
SSTn"TM COST OF C.,ONS.EZ UC CON
395=
PU,afiT FU 9L3MM1RY t
P1UMBINO F" ,^ 101-002"1.419-000 i Z,S4
ffUG.2002
CITY OF LA QUINTA
FINANCE DEPT.
INUB-TOTAL C0NVMTJCn0W AND PIAN CHELX
$22.10
LEM .PRE -PA ED PM33
$0.00
1WAL P1 1' FSS DUX NOW
2=30
/
RECEIPT
DATE
BY
DATE FINALED
INSPEC R
2
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O. _
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond'
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
r
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS.-)
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
4
P.O. BOX 1504
7&105 CALLE ESTADO
Address 51-980 martinet LA QUINTA, CALIFORNIA 92253
Owner
Hortaan, Straffin
maning
Address Box 457
City Zip Tel.
ldllltild 92349 714-y659--3531
Contractor
Straffin Development Company,
Same
City
State Lic. I City
& Classif. 539977 Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 ofahe Business and Professions Code;#and my license is in full force and
effect. a%- . I", .r',- - . I_i l
_SIGNATURE 1, 1 DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
Permit to construct, atter, improve, demoish. or repair any structure, prior to its issuance also
requires the applicant for such permit to ft a signed statement that he is licensed pursuant to
the provisions of the Contractor's License taw, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basts
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civilpenally of not more than rive hundred dollars ($500).
O 1, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Bulsness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or knproves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion. the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Bus -mess and Professions Code: The Contractor's License Law'
does not apply to an owner or property who buids or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified,copy,thereof. (Sec. 3800, Labor Code.)
Policy No. Company iC v
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Dale Owner
NOTICE TO APPLICANT: d, after making this Certificate or Exemption you should become
subject to the Workers' Compensation provfskm of the labor Code, you must forthwith
comply with such provisions or this pemdt shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant_ Dater-
Mailing
ateMailing Address
City, State, Zip
No. 05287
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 773--181-, 001
Legal Description
Project Description 1501 of 2* retaining wall
Sq. Ft. No. No. Dw.
Size - Stories, Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
stimated Valuation $2,250
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. +
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS t yq4`jj
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE IN$ECTTgR
Issued by: Date -Permit 11 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL SO. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
OTHER APPJEOUIP.
DRINKING FOUNTAIN.
SO FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
'
SO. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID a 1 Vi cSEWAGE
DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® 3Ac
HOUSE SEWER
LATHING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
` FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
OUND. REINfj/ 7
(
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM —
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
'
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
Building
Address 51-980 Hartinex
Owner
Nnrtx" Strsaff4n
TWIVI 4 4 a"
Address PA3x 457
City lZip ITel.
ress
City Zip Tela
State Lic. City
& Classif. 539977 Lic. #
Arcn., tngr.,
Designer
Address
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City( Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. i .✓_. % :3
SIGNATURE ,r'",r DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after. Improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by .any applicant for a permit
subjects the applicant to a cin? penafty of not more than rive hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such Improvements are not intended or offered for sale. If, however, the building
or Improvement is sold within one year of completion, the owner -builder will have the burden
or proving that he did not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No Company ,/4 Sc
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ anyperson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: h, after making this Certificate of Exemption you should become
subject to the workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
No. 05283
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number ?7o=laa1.4-1 t
,Legal Description
Project Description o rte,
Sq. Ft. 1417 No. No. Dw.
Size _ Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
7fJ '?AA
PERMIT
AMOUNT
Minimum Setback
Plan Chk. Dep. S250.00
Front Setback from Center Line
Plan Chk. Bal.
S 140.45
Const.
545.M
Side Setback from Property Line
Mech.
01)
INSPECTOR
Electrical
106. Sn
Issued by:
Plumbing
Validated by:
S.M.I.
Validation:
y
Grading
Driveway Enc.
Infrastructure
f 7
TOTAL S3.022. 9R
REMARKS
ii }.f •r .l.t'1m # 117Tt1l f — 27
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
1/12/89Permit
Issued by:
Date
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUM01NG FkES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
r
SLAB GRADE �/
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCTWORK
ROCKSTORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO. FT. ®
GAS (FINAL)
WALL SQ. FT.
DRINKING FOUNTAIN.
SO FT ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
%r
d
V
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REMARKS:
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® Vic
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK —
NO PLUMBING"'
UNDERGROUND
A.C. UNIT
COLL. AREA
r
SLAB GRADE �/
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
EWER OR S K1K
ROUGH WIRING
DUCTWORK
ROCKSTORAGE
FO D. REINF. ��
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
-$
LUMBER GR.
FINAL INSP.
FRAMING - dam/
/
FINAL INSP.
ROOFING
I
%r
d
V
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR�r
GAR. FIREWALL
LATHING
MESHO?J
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
' CERT. OCC.
ccurc cwwi
SIGNATURES11NITIALS
GARDEN WALL FINAL
Desert Sands Unified School District
CERTIFICATION OF PAYMENT
OF
NOTICE.. 7.81,SCHOOL FACILITY FEESUM
UMENT
TO: City of La Quint? CATE®, "OT DATE:
Department of Community Development
78-105 Calle Estado
La Quinta, CA 92253
This is to ertif that/1C
developer of_Poj which is
located at IUA,90 within
this District, has paid school facil• y fees imposed ursuant to the
authorit genera d by Government ode Sect'olt 53080 i t e a ou t of
$ �(
covering a total of square feet of ( ) resi a tial or
( ) industrial/commercial development and that building permits for
this footage in this development may now be issued by your jurisdiction.
I c� a,l M7 Cb %a - 11,34 H C
lOCQ�fo DESERT NDS UNIFIED SCHOOL DISTRICT
White - Building Department • Yellow - Facilities Planning • Pink - Accounting • Gold - Developer
(10)-37
v -L
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH17,7Assure Parcel No.
/ d'/ 0/0
ENVIRONMENTAL HEALTH SERVICES
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
RECEIPT NO. IO
Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to County speculations as indicated on the attached check list.
A non-refundable filing fee (see below) is required when the application is submitted. Check must be made payable to the County of
Riverside. Approval of this application shall remain valid for a period not to exceed one year from date of approval.
Q
VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'*
Z
t'
Q
U
Agent, Contractor, Contact Person
0 e v.
Phone 71 f<'
Address & Phone
a
°wnd,Q /YJg/v s T'/dgFF��'`'
Phone
Mailing Address
City State
Gq•
Zip
913 Y j
Job Property Addresp
I.S/' 8'0EA/i0AR
Legal Description Prop. (PM, Tract, Lot)
YXaT 1& am$;—
Lot Size )
Water A nc a
Use of Permk P/P, CU, etc.
OtherGL�e7
Soxiao
G Za vw
sw•F'��1 Ouse ��,v
t �Q
Dwelling, MH Site Prep, etc.
Signature Applicant
Date
CATEGORY: , REV CODE FEE_
C3� SUBSURFACE DISPOSAL 1236 5.00
CATEGORY: REV CODE FEE
❑ SITE EVALUATION UPON REQUEST 7349 $42.00
❑ MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
Z
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $11.00
Q
a. 1 at 4 Parcels (Each) 1236 $45.00
(Less than 1 year)
U .
b. Each Parcel after 4 7344 $16.00
❑ PRELIMINARY ELECTIVE 7352 $45.00
Uj
❑ Rereview (2nd review same panel) 7344 $16.00
EVALUATION (Attach DOH SAN 53)
Cl) -
❑ Site Evaluation in Conjunction with
❑ HOLDING TANK 7351 $45.00
Critical Area 7346 $86.00
❑ ALTERNATIVE/EXPERIMENTAL 7345 $13200
O Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $86.00
NIT DA
Holding Tank Agreements Completed ❑ Yes N
Certification of Existing S.D. System Required ❑ Yes .. N
WOCB Clearance required. (Attach Form ❑ Yes b No
DOH SAN 007, Santa Ana Region Only)
_
Solis Percolation Report Required.'' ❑ Yes
Special Feasibility Boring Report Required. ❑Yes N
Detailed Contour Plot Plans Required (1 to 5 ft. interval) 1. ❑ Yes
Otlter ❑ Yes
Staff Specialist Lot Inspection Required ❑ Yes No
Lot Inspection Date
gg
S�tls boong report bye ` Data
P ##
Sols Map Page Soil Type '-b, Date
Z
elling Uglls l (1) Septic Tank Soil Rate drease/Send
No of Systeme Type S s) [34
�� G Intcp
�
❑� `eplaoement nf'I.
-�".. 'C 41. vxu(aaJ�
I.0
Td's,
•
(2) Lech Ung: Fjty Sidewall allowance install s)� long Ira with L h Bed sq. ft.
trench area ft. rods/ �
sq. R min. incites rainlines or of
per running it
Leachlines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below
Seep%e P Drpth
'
Othe�
Applicable
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/
`
Inlet (BI)
Max. Alloyvpb0 Depth
j� /
N/A factor
1 ��
O /
o
No. 2 System % A--
REMARKS:
This application is PEROVEA - .?for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
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on the accompanied plot pl musing the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
at;ove-designed system. No construction is permitted in the required reserved 10096 expansion area.
Septic tank and sewer lines must be 50' minimum from any wells
1
(2 - Leach lines must be 100' minimum from any wells, including expansio ar
Seepage pits, must be minimum minimumfrom� any ells, includingex n/si nn a
D4Lti.
Signature of Health Official
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RECEIPT NO. IO
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Issued By 1&eI4
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DISTRICT:' ❑ Riverside, Indio
❑ Hemet ❑ Perris ❑
Rancho Calif. ❑. Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION:
WHITE - Office file YELLOW - Applicant
PINK - Bldg. Dept. GOLDENROD - Plans/Records
* 1.
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