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ELEC (13596) + PLBG (11769) + SFD (002443)54275 Avenida Martinez 13596 11769 002443 T4hf 4 4 Q" Building Address 54-275 Ave. Martinez Owner Diana Treiden Mailing Same Address City Zip Tel. La Quinta, CA *2253 Contractor F & P Pools VW Box 12206 P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Deserts dA 92255 ITe1.345-5070 State Lic. City & Classif. C53 476807 Lic. # 130 Arch., Engr., Designer Address Tel. CityI Zip I State I Lic. # LICENSED CONTRACTOR'S DECLARATION yyyyyyhereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 00) of Division 3 of the Business and Professions Code, and my license is in full force and ffect. SIGNATURE 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, alter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to file 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 civil penalty of not more than five 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 of proving that he did not build or improve for the purpose of sale.) 0 I, 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 contractors) 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 Pol. pensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Polic Company 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 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. Date Owner NOTICE TO APPLICANT: If, after making this Certificate or Exemption you should become subject to the Workers' Compensation provisions or 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 ateMailing Address City, State, Zip No. 13596 BUILDING: TYPE CONST. OCC. GRP. A.P. Number ,Legal Description Project Description Electric hook" -up for portable spa Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation $150.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. 15.00 Mech. Electrical Plumbing 15.00 .S.M.I. Grading Driveway Enc. Infrastructure TOTAL 3U.00 REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from,C ♦en eer r Line Side Setback from Pr- - FINAL DATE I Issued by: Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SO. FT. ® $ UNITS SLAB GRADE 2ND FL. SD. FT. BONDING YARD SPKLR SYSTEM FOR. 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 APPJEGUIP. 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 FRAMING GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY 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. SO. FT. ® c BATH TUB SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1+/4 c SEWAGE DISPOSAL SO.FT.GAR ® 3/ac 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 GROUND PLUMBINGS UNDERGROUNDS _ 6�� 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 FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEGUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. GRADING cu. yd. $ plus x$ _$ LUMBER GR. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL Building 54--275 MARTINEZ TAhf QUM& 44 P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 No. 1769 Owner BILL WAGGONER BUILDING: TYPE CONST. A.P. Number OCC. GRP. ' Mailing Address 42-650 $ONDORAS PLACE City Zip Tel. BERMUDA DDN S 92,201 345-1631 Legal Description Project Description SEVER ROOKUP Contractor ECONO SEVER SERVICE Address P 0 BOX 192 CityZip PALM DESERT Tela 346-2793 State Lic. & Classif. C-42 480961 City - Lic. # Sq. Ft. No. No. Dw. Size Stories Units Arch., Engr., r Designer New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑ Address Tel. City Zip State Lic. # / LICENSED CONTRACTOR'S DECLARATION ✓ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing,wilh Section 70 00) of Division 3 of the.B`,us iness and Professions Code, and my licens eyis, in ful fo a and effect.r.._ . Yir ac. ,M SIGNATURE I, 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 file 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 civil penalty of not more than five 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 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 of proving that he did not build or improve for the purpose of sale.) O I, as' owner of the property, am exclusively contracting with licensed contractors to con- Strutt 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.) ❑ I am exempt under Sec. B. & P.C. for this reason Estimated Valuation $1,200 PERMIT AMOUNT Plan Chk. Dep. ' Plan Chk. Bal. , Const. Mech. Electrical Plumbing 43().00 S. M. 1. Grading Driveway Enc. Date Owner Infrastructure 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.) Poliriy7 NO. Company Copy is filed with the city. ❑ Certified copy is hereby furnished. TOTAL V • Q 0 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE REMARKS tp'./n aa ««yy n • t[ 051 Z1i L, 10 .4422— 01-25-9.3 (s (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 any person in any manner so as to become subject to the Workers' Compensation Laws of California. a'.r t+r Yaa y1 a, i Q f Fit- I 3'l,+ VV Date Owner NOTICE TO APPLICANT: If, 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. ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line 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.) Side Street Setback from Center Line Side Setback from Property Line Lender's Name _ FINAL DATE INSPECTOR 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 sof this city to enter the above-. mentioned property for inspection purposes. Issued by: Validated by: Date Permit Signature of applicant Date Mailing Address Validation: City, State, Zip CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEE- 1ST FL. SQ. FT. ® $ UNITS r r BONDING YARD SPKLR SYSTEM 2ND FL. SO. FT. FORMS SEWER (iR-666716-T ROUGH WIRING MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® GAS (ROUGH) METER LOOP GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. SQ. FT. TEMP. POLE DRAINAGE PIPING WALL SQ. FT. GROUT DRINKING FOUNTAIN. SO. FT. ® FINAL INSP. URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER SYSTEM WATER PIPING NOTE: Not to be used as property tax valuation =$ FLOOR DRAIN MECHANICAL FEES FINAL INSP. WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM VENTILATION 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 GAR. FIREWALL SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 11/4 c SEWAGE DISPOSAL SQ.FT.GAR ® 3/ac 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 FEF7 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 (iR-666716-T ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP./EQUIP. 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 INSULATION/SOUND FINISH GRADING FINAL INSPECTION `x-)143 CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL CASH RECEIPT DETAIL N-0 41 6 Received From: Date: Address: /2 Account No. Lot(s) Tract Service Address G.A. Code 0 Meter(s) 0 Service(s) 0 Backflow ,,(s) 0 House Lateral(s) 0 Detector Check(s) 0 Meter Surcharge P- anitation Capacity Charge 0 W.S.B.F.C. 0 Temporary Construction Meter 0 Turn on Charge 0 Uncollected Account - Name 0 Inspection Fee - Tract - Fee - 0 Plan Check Fees Water / Sewer - Tract - 0 Bond Payment - A.D. - Bond Assmt. 0 Customer Deposit 0 Other Remarks: CEJf J, 0 COPY to: Cash Check Money Order -Z 57 TOTAL $ Water Service Cashier CViND-438 (11/89) Building Buaki... 275 Meni& iT*Z P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Owner I mailing - Address 655 nalt camm Lr. JbAte 100 City Zip Tel. WM Contractor £may Sazxi 0mulft"t1Nftuall 0D. Address Sam City JZip I Tel. State Lic. I City & Classif. 472924 Lic. # Arch., Engr., Designer Address Tel. City_ (Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION y 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. SIGNATURE 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, alter, improve, demolish, or repair any structure, prior to its issuance also P requires the applicant forsuch permit to file 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 subjectstheapplicant to a civil penalty of not more than five hundred dollars ($500). O Ias owner of the property, or my employees with wages as their sole compensation, will i do tie 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 of 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.) O I 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 ❑ Copy is filed with the city. O 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 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. Date Owner NOTICE TO APPLICANT., If, 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 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 toenter the above- mentioned property for inspection purposes. Signature of applicant / Date Mailing Address City, State, Zip HARD COPY No. 002443 BUILDING: TYPE CONST. OCC: GRP. A.P. Number. 774-253-013 Legal Description lot 2 Project Description Wale famuy N0111' BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line MG M4 Sq. Ft. cm so Size . _ No. No. Dw. Stories Units New EX Add 0 Alter ❑' Repair ❑ Demolition ❑ INSPECTOR 7-7"'86 Issued by: Date Permit Validated by: Validation: A59G4 7 2 7%25.96 U Estimated Valuation 71A`911200 PERMIT AMOUNT Plan Chk. Dep. ar3.it(1 Plan Chk. Bal. .50.35 Const. 349.00 Mech. 30.00 Electrical 74.22 Plumbing 99.00 S. M.I. 5.01 Grading 2D.0 Driveway Enc. 20.00 Infrastructure 1,078.38 TOTAL 1 1,975.96 1 1.725.96 REMARKS 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 7-7"'86 Issued by: Date Permit Validated by: Validation: A59G4 7 2 7%25.96 U CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. ® $ 2ND FL. SO. FT. ® POR. SO. FT. ® GAR. SO. FT. ® CAR P. SO. FT. ® WALL SO. FT. ® SO. FT. ® ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation BONDING FLOOR DRAIN MECHANICAL FEES FORMS 7 WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GAS (ROUGH) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APPJEOUIP. LAUNDRY TRAY AIR HANDLING UNIT CFM TEMP. POLE 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 FRAMING SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL SO.FT.GAR ® Y4c 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 ROUND PLUMBING /-/ UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS 7 R SE70 ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. TV FINAL INSP. i GRADING cu. yd. $ plus x$ =$ LUMBER GR. FRAMING ROOFING// 8 REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL ►L( LATHING .q MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL 1ED `'ti o i o _= _o w BERMUDA DUNES RANCHO MIRAGE INDIAN WELLS H PALM DESERT a d` LA OUINTA 100 INDIO Desert Sands Unified School District 82-879 HIGHWAY 111 • INDIO, CALIFORNIA 92201-5678 • (619) 347-8631 June 30, 1986 City of La Qui vita Department of Community Development 78-105 Calle Estado La Quinta, CA 92253 Re: 54-275 Martinez Gentlemen: The developer of the above referenced lot has mitigated its impacts on our overcrowded schools by payment of the amount of $628 per unit to be applied to the cost of district educational facilities made necessary by such new development. Sincerely, ' L John D. Brooks Assistant Superintendent Business Services JDB/crm OUNTY OF AL LTH SERVICES DIVISION CPERMIT 4PPLICATION FOR ARSUBSURTFACE SAEWAGE DISPOSAL SYSTEM -7 v Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to unty specifications required on the attached check list. A non-refundable filing fee of 30 is required when the application is submitted. Check must be made payable to the ounty of Riverside i Building Department Application Log N a Z 0 H H W U) Name (Owner, Agent, Contractor, Etc.) Mailing Address Initial Certification of Existing S.D. System reqd. Yes[ City State Zip Code Telephoen Mavw e- WQCB Clearance reqd. Yes[ ] NoG , * 'ob Prope y Address*f C`ity_orjCo *Legal Descf:iption ofd pty. Lot, PM, Detailed boring report reqd. Yes[ TR) *Assessor's Parcel No. ri Water Agency Use of Permit - f Yes[ Lot Size -:263 -e",3 _7.l SFD, MH Site Prep Etc. 77il —UPlanning ( l E Case !! ¢ a /vdw A A .oQIJI+ELIO w w./O, V((` ^, f /1 t ID/ Signature of'Applican Date ` - *The above information must be verified from Building Application STAFF USE - DO NOT WRITE BELOW THIS LINE Date 4 - i .A Type of System: No. of Bedrooms) (1) Septic Tank Soil Rate Required Existing New Addition Replacement Gals. [ ] [ ] [ ] [ ] 3 • Y . /may (2) Leach line sq. ft. Sidewall allowance Install Lines Leach bed (1tpm trench area) t oock/ Sq. Ft. Ft. L olPg ,,- Ft. wide Sq. Ft. of per, --r 6i;n; ft. with Min.._-- inches rock botto N/A [ ] " • below drain linesw area Leach lines/bed-special design (3) Pit Diamete No. Pit Seepage Pit total depth for slope:,Applicabley 6'[V Pits BI N/A Overburcten-factor I / -rage depth v dt lu" 1+ `►. This application ip-'approved for the design of a subsurface disposal s --stem as indicated on the accompanied lot plan using the requirements set forth in Section B above. 0 A building permit is necessary for the installation of the above -designed system. H//Septic tank and sewer lines must be 'S0' from any wells-//(, / ,,r;?, cL-4 Y 1-/J / ' '' ' E+(2) Leach lines must be 100' min. from any wells including ex ansion area v W (3) Seepage pits must. be 150' min. from any wells including expansion areape,v ,'.+'`'S ;r )' 'Signature of Health Official" / Date RECEIPT NO.. n, 4 ., ;t 1, , . 2,1 Issued by 4rie Date 6— , ;! District: River's° det[sj Indio [✓]Hemet [ ] Perris [ ] Rancho Calif. [ ] Blythe [ ] Distribution: WHITE -Office file YELLOW -Applicant PINK -Bldg. Dept. GOLDENROD -Fending File DOH SAN 122 (Rev. 2/86) Initial Certification of Existing S.D. System reqd. Yes[ ] No WQCB Clearance reqd. Yes[ ] NoG , Soils feasibility report reqd. Yes[ / ] No Vi Detailed boring report reqd. Yes[ ] No.f/7/ zDetailed contour plot plans reqd. Yes[ ] Nor.,A 0 PStaff Specialist approval reqd. Yes[ ] No[/7 Lot Inspection Date w Soils/boring report by N Date n Soils Map Page r ? Soil Type ('4C Approved by /_Proj. / / ' % Date Date 4 - i .A Type of System: No. of Bedrooms) (1) Septic Tank Soil Rate Required Existing New Addition Replacement Gals. [ ] [ ] [ ] [ ] 3 • Y . /may (2) Leach line sq. ft. Sidewall allowance Install Lines Leach bed (1tpm trench area) t oock/ Sq. Ft. Ft. L olPg ,,- Ft. wide Sq. Ft. of per, --r 6i;n; ft. with Min.._-- inches rock botto N/A [ ] " • below drain linesw area Leach lines/bed-special design (3) Pit Diamete No. Pit Seepage Pit total depth for slope:,Applicabley 6'[V Pits BI N/A Overburcten-factor I / -rage depth v dt lu" 1+ `►. This application ip-'approved for the design of a subsurface disposal s --stem as indicated on the accompanied lot plan using the requirements set forth in Section B above. 0 A building permit is necessary for the installation of the above -designed system. H//Septic tank and sewer lines must be 'S0' from any wells-//(, / ,,r;?, cL-4 Y 1-/J / ' '' ' E+(2) Leach lines must be 100' min. from any wells including ex ansion area v W (3) Seepage pits must. be 150' min. from any wells including expansion areape,v ,'.+'`'S ;r )' 'Signature of Health Official" / Date RECEIPT NO.. n, 4 ., ;t 1, , . 2,1 Issued by 4rie Date 6— , ;! District: River's° det[sj Indio [✓]Hemet [ ] Perris [ ] Rancho Calif. [ ] Blythe [ ] Distribution: WHITE -Office file YELLOW -Applicant PINK -Bldg. Dept. GOLDENROD -Fending File DOH SAN 122 (Rev. 2/86)