Loading...
PLBG (05-1039)G' Tdf 4 4, a" BUILDING & SAFETY DEPARTMENT Box 1504 (760).777-7012 95 CALLE TAMPICO FAX (760) 777-7011 INTA, CALIFORNIA 92253. INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT A A ication Number 05-000MVENIa-A 9 ,Date 3/23/05 roperty Address. . . . . . . 52165 MENDOZA APN: 773-232-019-8 -000000- Application description . . . PLUMBING Property Zoning . . . . . COVE RESIDENTIAL Application valuation 2500 Owner Contractor ------------------------ ------------- ----------- KEN JOHNSON SO CAL PLUMBING & REPIPE CO P.O. BOX 3921 P.O. BOX 955 PALM DESERT CA 92261 YUCCA VALLEY CA 92286 (760) 369-4104 WCC: EXEMPT WC: EXEMPT 11/30/05 CSLB: 793482 04/30/05 CCC: C36 -C42-13 --------------------------------------------- ------------------------------ Permit . . . . . . PLUMBING SEWER Additional desc Permit Fee 30.00 Plan Check Pee .00 Issue Date . . . . Valuation . . . . 2500 Qty Unit Charge Per Extension BASE FEE 30.00 --------------------------------------------.-------------------------------- .Special Notes and Comments SEPTIC ABANDON; SEWER CONNECT Fee summary Charged Paid Credited ;Due --------------------------------------------------------- Permit Fee Total 30..00 .00 .00 30.00 Plan Check Total .00 .00 00 .00 Grand Total 30.00 .00 .00 30.00 P.O. BOX 1504 • VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 05— (O 3 9 Date: J-.23-05 Applicant: I Architect or Engineer: Applicant's Mailing Address: Architect or Engineer's Address: D 1A Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION 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 ss L' se is full f,grce�n ct. , rZ— /_Cicense Class C5(S G �— ,cense No. i�ra OWNER -BUILDER DECLARATION ' I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she 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).): U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself or through his or her own employees, provided that the 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 or she did not build or improve for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. , BA P.C. for this reason Date Owner. WORKERS' 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. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy Number 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 to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. ateA¢I WARNING: FAILURE TO SECURE GµARtE2R TOMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 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 county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the abov - �� J ignature (Applicant 711 Received Fr V t ' Address: C4 rY' Account No. / Lot(s) Service Address ' ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ Detector Check(s) ❑ Mete�urcharge[B�nitation Capacity Charge l� ❑ W.S.B.F.C. ❑ S.I.W.S.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - Tract - 0. Bond Payment -A.D. - Bond Assmt ❑ Customer Deposit ❑ Other Remarks: Co<Yt G.A. Code s TOTAL s oZ2 2 � � Water Service Cashier CVWD-438 (1/05) KEN JOHNSON L =- 214. P O; BOX 3921 �• L Lam` PALM DESERT, CA 92261 " G:' e" K I N G" t `L 6 S PAY TO THE ORDEROF. 0a 7 n6r (�t i11s1� lls�=t Y�! ) v DOLLARS UNION BANK OF CALIFORNIA 16-49 407 PAUA DESERT #407 1220 73-785 El PASEO AVENUE, PAun DESERT, CA 92260 4071086542 800 S 4 _ko ww 1: 1 2 200049611: ^ 40 7' 0$6 54 211' HAMMER PUMPING INC. P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 17GA1 ZRA_7AA4 JOB INVOICE QUANT. CUSTOMER'S ORDER N0. DATE OR RED (760)321-7448 Gallons ,00 ORDER TAKEN BY DATE PROMISED 0 A.M. 0 P.M. BILL TO PHONE ADDRESS ^ / �y►V_ A - Sj, J ''(✓#�'(_/, Dumping Fee per 1000 gal. MEOHAN CITY 3G 9- HELPER ' JOB NAME AND OCATION Out of Area Fee 0 DAY WORK 0 CONTRACT DESCRIPTION OF WORK Locating / Opening Fee (per hour _ 0 EXTRA v Size System: tl QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT Gallons ,00 Pumping Fee per 1000 gal. Dumping Fee per 1000 gal. Out of Area Fee Locating / Opening Fee (per hour _ Size System: tl A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS. 18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. HOURS LABOR AMOUNT TOTAL MATERIALS ` / MECHANICS @ HELPERS Q TOTAL LABOR hereby acknowled a -the satisrac or— f y—"'- cwplet'o iSne a ov-60fflbed-wer- �-- . TOTAL LABOR TAX �91'�.NATURE - - �� ✓ DATE COMPLETED TOTAL`S (¢� 4 P.O. BOX 1504 r � No. 9716 Building 52165 Ave.7&105 CALLE ESTADO f F Address Mendoza LA QUINTA, CALIFORNIA 92253 ( r Owner L- j Joe Steller BUILDING: TYPE CONST. Mailing OCC: GRP. Address 73940 Horseshoe Read A.P. Number 773-232--019 City Zip Tel. L8 Quinta 92253 342-3170 Legal Description Lot 8 Block 95 Unit 11 Contractor _ Project Description SFf3 Zip State Lic. City & Classif. I Lic. # Arcn., Lngr., Designer Address CityI Zip I State I 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 effecI. 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). OKI, 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.) ❑ 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 contractor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Sec. B. & P.C. for 111"s reaso Date Owner --TWA( �_- a t If I WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 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.) 1 certity.that in the performance lot thg work for which this permit is issued, I shall not employ any person in any manner so as to become subjjEct loathe Workers' Compensation Laws of California. J - _ Date -owner NOTICE TO APPLICANT, If,!aRer;making this Candleste-- xemptio a should become subject to the Workers' Compen7gadon provisions of the Labor Code, you must forthwith comply with such provisions &Z.Vermit 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 carlity 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 Dale Mailing Address City, State, Zip _005 Q44 0. Vl.�. Ki -Lia ;y_ 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 Issued by: Date Permit Validated by: Validation: Sq. Ft. 1250 Size No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Permit does not include block wall or pool Estimated Valuation 73,850.50 PERMIT AMOUNT Plan Chk. Dep..' 250.06 Plan Chk. Bal. 195.81 Const. 522.50 Mech. 32.50 Electrical 115.39 Plumbing 141.00 S.M.I. 7.50 Grading 2p .00 Driveway Enc. 20.00 Infrastructure 1616.02 TOTAL 292U . ' 2670.72 REMARKS IR _005 Q44 0. Vl.�. Ki -Lia ;y_ 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 Issued by: Date Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SQ. FT. ® $ 2ND FL. SQ. FT. POR. SQ. FT. ® GAR. SO. FT. ® CAR P. SQ. FT. ® WALL SQ. FT. ® Sp 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 SLAB GRADE �S 9� FLOOR DRAIN MECHANICAL FEES BONDING WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER PfIC TANK GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED ROCK STORAGE LAUNDRY TRAY AIR HANDLING UNIT CFM LOOP 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 SERVICE SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1Vi c SEWAGE DISPOSAL WATER SYSTEM SQ.FT.GAR ® 314c HOUSE SEWER LUMBER GR. GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES - MICRO FEE I I MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK '7 /7 GROUND PLUMBING ,, / UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE �S 9� ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS PfIC TANK ROUGH WIRING. DUCT WORK ROCK STORAGE ,/I FOUND. REINF. �sQ�/" ' s GAS (ROUGH) 0 g !�__METER fJ 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. �Q/� FRAMING 2 / FINAL INSP. /` / (/ F /q / ®) � /q L Q C/ P O REMARKS: -ROOFING VENTILATION FIRE ZONE ROOFING , FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION-` CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINRIALS GARDEN WALL FINAL DESERT SANDS UNIFIED SCHOOL DISTRICT 82-879 Highway 111 NOTICE: Indio, CA 92201 Document Cannot Be Duplicated (619) 347-8631 Date' 6/27/91 1 Type of Permit I La Quinta No. 10695 Permit # Log # Owner Name Joe Stemmer No. street See Below city La Quinta zip 92253 Study Area 112 APN # Tract # J Lot # Square Footage 12,400 Type of Development I Single Family Residence No. of units Comments 53-225 Obregon (Area 111)and 52-165 Avenida Mendoza (Area 112) Raeh home is 1200 s =mare fppt At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: EXEMPTION NOT APPLICABLE This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 1.58 X ®or $ 3,792.00 have been paid to D.S.0 S.D, for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By JoeNicky Stemmer Telephone 342-3170 Name on the check By Richard M. Beck Director, Facilities Planning & Development -P, ;i�� J F Fee collected /exempted by Shelley D. Bennetto e Payment �R;Zceive , � Signature Ch®ck,�iVo 238 .{ A Collector: Attach a copy of county or city plan check application form to district cnpy fcir's !!waivers. Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting RECORDING REQUESTED BY FIDELITY NATIOt'IAL TITHE INS. CO. AND WHEN RECORDED MAIL THIS DEED AND, UNLESS OTHERWISE SHOWN BELOW, MAIL TAX STATEMENTS TO: F J I JOSEPH W. STEMMER . 79 4p Hg3595HAE ROAD LA QUINTA, CALIFORNIA 92253 -4L ESCROW NO. TITLE ORDER NO 1024-24-14473-2—JR / /ate ,S R too u tt y 0. Cn 'tq� 0� W •� v ,N ` � U Cn + a vt d C9 Jy Etl �. SPACE ABOVE THIS LINE FOR RECORDER'S USE GRANT DEED Tile undersigned grantor(s) declare(s): 773-232-019. Documentary transfer tax is $ 17.05 A.P.N. ( X ) Computed on full value of property conveyed, or ( ) Computed on full value less value of liens and encumbrances remaining at time of sale. ( ) Unincorporated area: ( X ) City of LA QUINTA , and By this instrument dated TWENTY—SIXTH DAY OF APRIL, 1991 , for a valuable consideration . FRED SASS, TRUSTEE OF THE F.S.D.R.H. TRUST, dated November 19,1984 hereby GRANTS to JOE W. STEMMER, A MARRIED MAN AS HIS SOLE AND SEPARATE PROPERTY the following described real property in the CITY OF LA QUINTA County of RIVERSIDE , State of CALIFORNIA LITA LE UINA, AS LOT 8, FILESINrBOOKT18, PAGE 75OF SOFTMAPS,RRECORDSTINATHELOFQFICETSHOWN OF THE ON COUNTY BY MAP ON RECORDER OF RIVERSIDE COUNTY, CALIFORNIA STATE OF CALIFORNIA,/r COUNTY OF % � /FFRRED ASS TRUSTEE Onbefore me ss the undersigned, a Notary Public in and for said County and State, personally appeared ATTACHED TO GRANT DEED DATED 4/26%91; FRED—SASS. - STATE OF NEVADA CLARK:` ss. Countyof........................................................................I...................... t....o On this................2ND............................................................ day of .. MAY............................................................. A.D. one thousand nine hundred and .........9....1 .................................................. CQ BARBARA LEE MORRISON ,aNotary pubb'einand for said � personally appeared before me.........................................................................................................................................:.......................................................................... i riCwnry of ............. CLAR.K.x......... FRED .....SASS ..............................:.....................................,.................................................................:...........................:.......................:..........:............................,.....................,..............,........... d• Barbara Lee Morrison Notary Public - Nevada Y +,1 Clark County My appt. exp. May 2, 1. 994 known (or proved) to me to be the person...... described in and who executed the annexe mstrument, w 4 acknowledged to me that...... he executed the same, freely and voluntarily, and for the uses and purposes therein mentioned. IN:Wr17NESS WHEREOF, I have hereunto set my hand and affixed my Official Seal at my office in CLARK the Couhly.of............................................... ..:. ,the day and year m this certificate first above �i�itten.� Notary Public in and for the County of.......... C......................................... ....................................... State of Nevada: MAY 2, 1994 .........:.......................... FS -12 ' COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH AtsMtitasbaann�INo. - ENVIRONMENTAL SERVICES DIVISIONS PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to Count' speculations as indicated on the attached check list � (jr,,A ,-*refkindaP1a-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. QVERITY ITEMi1W SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG # 0� LO1 � V'i7A.3'1 P t Contractor, Confect Person Phone Address & Firm 15 f!A Owner �JC7G Phone L Mailing Address gggo City Sta a LA I� Zip Job Property Address X35 t�� r'ti�vr �RIk Vis' i , A. 1i Lot Size r Water nc�YVelf Use of Permit P/P, CU, etc_; r4 tri 4c4 -_* Other LU C rDwellfng Site Prep, etc." Signature of Applicant Data �f CATEGORY: REV CODE FEE"O " — I� SUBSURFACE DISPOSAL 1238 $'57s00r �s CATEGORY: REV CODE IEEE i SITE EVALUATION UPON REQUEST 7349 $ 43.00 m [3 MULTIPLE PARCELS WITHIN SAME ,0„1'_ (NO PLOT PLAN) Z LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $ 17.00 O a. 1 at 4 Parcels (Each) 1238 $ 57.00 (Less than 1 year) b. Each Parcel after 4 7344 $ 24.00 ❑ PRELIMINARY ELECTIVE 7352 $ 23.00 ll1 ❑ Rereview (2nd review same parcel) 7344 $ 24.00 EVALUATION (Attach DOH SAN 53) U) ❑ Site Evaluation in Conjunction with ❑ HOLDING TANK 7351 $ 47.00 Critical Area 7348 $111.00 D ALTERNATIVE/EXPERIMENTAL 7345 $222.00 ❑ Site Evaluation Lot Less than SYSTEM 10,000 Sq. Ft. 7347 $ 87.00 INfTI �% DATE Holding Tank Agreements Completed ❑ Yes 0`" N, AM— t7r — eov + : Certification of Existing S.D. System Required ❑ Yes ©' 1 3 _Noo WOCB Clearance required. (Attach Form ❑ Yes N� o DOH SAN 007, Santa Ana Region Only) Sails Percolation Report Required. ❑ Yes 2110 Special Feasibility Boring Report Required. ❑ Yes El Detailed Contour Plot Plans Required (1 to 5 fl. interval) ❑ Yes �" o•" OUner ❑ Yes Staff Specialist Lot Inspection Required ❑ Yes ❑ No Lot Inspection Date Soils boring report by /Date` Project D Soils Map Page l 1 Sod Type Approved by �~�� Date U r Z No. of system Type of Systems) No. Dwelling Units r(} (1) Septic Tank t Soil Rate Greeee/Send O ❑ Ing Tank ❑ Existing 0 ❑ Replacement Bedrooms, Fixtu`fTUntts'- 3 6'011m � Intop �Gr Gal P Ge! U) (2hLsech Line Sq. FL trench arae Sidewall allowance Install Lne(s) fL long / h wide with Leach Bed sq. tL fL rock/ sq. f . ter/ per running fL 011%r NA min. rcf Trodc,txalow drakrlines or of Leachlines/bed special design for slope: (3) Pit Diameter No. Pita Pit Below Seepage Ph,T� Depth (TD) �� Other. Applicable r" �to_%erWrden l> 6 Q Inlet (81) Ili t Ff Max. Al""Is Depth N/A factor No. 2 Systemfi �} e� REMARKS: -=�f�_�ii�� f ..�1 �"�,�� c� Lam,-s-••�-�.�. i Y This` application is? PPROVED > ENIED•for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated r Z on the accompanied plot Ian using., equirer _eaJA q,foRfa,.ir�SEG�10M,�above.,..A�buildmg�.permit is necessary for the installation of ft above -designed system. JNo construction is permitted in the required reserved 100% expansion area `c Septic tank and sewer lines must be 50' minimum from any wells W// 7J, tj,: W �). Leach lines must be 100' minimum from any wells, including expansion area (3 Seepage pits must be 150' minimum from wells, including expa/nn n area fQ U), �any Signature of Health Official f4fi� /6CG,s, fc—>"Dater ` t/ RECEIPT NO. 13 6 . ✓(p' T // Issued By AddtDate 4 DISTRICT: D Riverside, © ndi6 ❑ Hemet ❑ Perris 0 Rancho Calif. D Blythe OH -SAN -122 (Rev. 3/90) DISTRIBUTION: WHITE Office file YELLOW - Applicant PINK -Bldg, Dept GOLDENROD - Plans/Records t I -