04329 (SFD)M
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COUNTY OF RIVERSIDE, ENVIRONMENTAL HEALTH SERVICES DIVISION
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 County specifications required on the attached check list
A non-refundable filing fee of:$40 is required when the application is submitted- Check must be made payable to the County of Riverside
Building Department Application Log #
Name i0wher, Agent. CRntractor, Etc.)
Mailing Address
City
Slate
Zip Code
Telephone
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'Job Property Address f�7 - •.., C
'Ci1.Fifuru( 'Legal Descnphon el Properly (Lot. PM TR)
4.Use
'Assessors Parcel No
Lot Size
7.3 - .2 U"— � . Sr
►�, ��
L�accii
of Permit- Plannirig,Case s
P, 5r,t d,7—
SFD. MH Site Preparation Etc
Srgnature of imM Dale
'The above information must be verified from Building Application
STAFF USE — DO NOT WRITE BELOW THIS LINE
Initial Date
Certification of Existing S.D. System required ❑ Yes ❑ N� `7
❑ ❑
WOCB Clearance required. Yes Nolw_,�'
Soils feasibility report required. ❑ Yes ❑' No
Special feasibility boring report required. ❑ Yes ❑ _No I
Detailed contour plot plans required. ❑ Yes ❑ No
Staff Specialist approval required. ❑ Yes ❑ No Lot Inspection Date
Soils/boring report by Project # Date
Soils Map Page ' Soil Type t�Approved by— _ _ Date
Type of System
No. of Bedrooms (1) Septic Tank
Soil Rate Required
❑ Existing ❑^IVew El Additional El Replacement
Gals.
(2) Leach line sq ft.
Sidewall allowance
Install Line(s)Ft- Long,
Leach bed Sq
(Bottomtrneh are_ a)
ft. rock/ Sq Ft.
Ft wide with min. inches
Ft. of bottom
�.
per running ft. 0•N A
rock below drain lines
area
Leach lines/bed-special design for slope:
(3) Pit Diameter
No Pits
Pit BI
Seepage Pit total depth
Applicable_,---
N/A Overburden factor
0�5 ❑ 6'
,
�, -
Max allowable depth
This application Isapproved-(,denied for the design of a subsurface disposal system as indicated on the accompanied plot plan using the requirements
set forth in Section above. A building permit is necessary for the installation of the above -designed system.
f(1) Septic tank and sewer lines must be 50' from any wells -> - ',� ,t" •r t ` 4Z.
Leach lines must be 100' min. from any wells including expansion area
#rSeepage
pits must be 150' min. from any wells including expansion area . t ff:�
r-4,
Signature of Health Offioat
RECEIPT NO Issued by "` Date
District: ❑ Riverside ❑ T' dio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe
Distribution: WHITE —Office file YELLOW —Applicant PINK —Bldg Dept GOLDENROD —Pending File
DOH SAN 122 (Rev 8/87)