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04825 (SFD)Bujlding .53-725 Carranza Arlrlracc Tiht 4 4 Q" P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Owner Coachella VallaV Lard Mailin Address 247 E. Tahquitz Way 2 � .. City I Zip Tel. willm sprin(•o. 92262 >t~ft 32i -11020R R Contractor Starr Conotruction Address City Zip Tel. w..a State Ljc. Cit 30793 1Lic.y # $95 & Classif. Designer Address Tel. CityI 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 effecI . .d: K,- I� ,?w-,��+'.,rL%•.X'_-.. '"k.�...,.� /i ftA 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, atter, 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 or the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or thathe 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). O 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 or 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- 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 1 am exempt under Sec. B. & P.C. for this reason Date Owner i WORKERS' COMPENSATION DECLARATION I I hereby affirm that I have a certificate of consent to: selfjhsure, or a certificate of Worker's Compensation Insurance, or a certifiedcopy'therreo(�3800. Labor Code.) Policy No. Company Z O Copy is filed with the city. 0 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 (E100) 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. 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 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 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 Date Mailing Address City, State, Zip 048425 BUILDING: TYPE CONST: OCC. GRP. A:P. Number - • 774-115-022 Legal Description Project Description �'' • Sq. Ft. 1409 No. No.:Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ 430' Garalze 170'X 61 wood fence Estimated Valuation $76v105 PERMIT AMOUNT Plan Chk. Dep. $250.00 Plan Chk. Bal. $ 64:D05 Const. 364.00 , Mech. 36„00 Electrical 74.17 Plumbing a 105.00 S.M.I. : J0 Grading A U0 Driveway Enc. Infrastructure •=� TOTAL 0.4 r 01?$ w 4t J REMARKS } {rr 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 RECTOR. Issued by: Date Permit Validated by: Validation: 1 WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES tST FL SO F1 pr S UNITS COLL. AREA .UiB GRADE/ ROUGH PLUMB YARD SPKLR SYSTEM 2ND FL SO FT. s$ HEATING (ROUGH) STORAGE TANK FORMS MOBILEHOME SVC. BAR SINK POR SO FT. gr DUCT WORK ROCK STORAGE GARSO. FT. or POWER OUTLET ROOF DRAINS HEATING (FINAL) DRAINAGE PIPING CAR P. I SO FT. rpt GAS (FINAL) TEMP. POLE WALL SO FT. (d DRINKING FOUNTAIN SO FT fd WATER HEATER URINAL ESTIMATED CONSTRUCTION VALUATION S 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.COOL HOOD SIGN WASHER(AUTOXDISH) APPLIANCE DRYER FINAL INSP. GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY 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 SPARK ARRESTOR - SO. FT. c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID 1'A c SEWAGE DISPOSAL LATHING SO.FT.GAR rg 3i c HOUSE SEWER MESH GAS PIPING PERMIT FEE INSULATIONISOUND 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 2 2rj ROUND PLUMBIN UNDERGROUND A.C. UNIT COLL. AREA .UiB 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 APP.IEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ -plus-x$ c $ 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 SIGNATURESIINITIALS GARDEN WALL FINAL DATE 7—�'� - CASE tb. IC fs/jK S F DEVELOPER'S NAMEt S T R R R ADDRESS t S%7 Tod /VQct r r`.z P PALM SPPOWC-r$ dh 9 Z24� TELEPI IONE t(1, ) 3 2 2 C3 L -or i i3L 233 k Dear Developers After reviewing your landscaping plans, all JAM it material listed is not in violation of quarantine laws govembig the Coachella Valley. • If substitutions do occur and they differ frcxn plant material li'''sted, this office nnist be notified immediately. Thank you for protecting and pteservitig the Coachella Valley's pest -free envi.r timnt. Ag icultural Cannissiof is office 'cc: Indio and Riverside Office 0 rf of f ICE of E. LEON SrnUCY s AGRICULTURAL CO3MMISSIONCRt IoS0,��s.Fo ? 1n"IE5 o WALLACE AN Iu WIStAM r )MM*5WtR '� M , r1 �� WEIGHTS Et MEASURE5 CLENIE`�t BE`vENISIE su�cn ' . • t 49-613 ttwy 86, Bvite 0-12 �b`,�+ ����,�•'� 'Coachella, CA 92236 4r q, eq 619-342-8291 DATE 7—�'� - CASE tb. IC fs/jK S F DEVELOPER'S NAMEt S T R R R ADDRESS t S%7 Tod /VQct r r`.z P PALM SPPOWC-r$ dh 9 Z24� TELEPI IONE t(1, ) 3 2 2 C3 L -or i i3L 233 k Dear Developers After reviewing your landscaping plans, all JAM it material listed is not in violation of quarantine laws govembig the Coachella Valley. • If substitutions do occur and they differ frcxn plant material li'''sted, this office nnist be notified immediately. Thank you for protecting and pteservitig the Coachella Valley's pest -free envi.r timnt. Ag icultural Cannissiof is office 'cc: Indio and Riverside Office 0 fs iv� - Gt/axfo oL . RECEIPT NO. r 3 Y7 Issued By Date %' 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 za COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH,Assessors Parcel No. 77lT ENVIRONMENTAL HEALTH SERVICES //r - D 2 i 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 speculations as indicated on the attached checklist 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 Q Agent, Contractor, Contact Person Phone Address & Phone U_3 D 3 -/o Zd lJ l Owner Phone Mailing Address In Z, 0111L State Zip Job Property Add Legal Description Prop. (PM, Tract, L0) gyp. f zi.e- s 'Oeo ./ .t3G _01 Lot Size ater A enc r ' Use of Permk P/P, CU, etc. 1,4 Q a, A17'A Other / / � �/�U �� g `n4 d �S' 1 sill g,MH Sit Prep, etc. / Date Signature Applicant CATEGORY: REV CODE FEE CATEGORY: REV CODE FEE SUBSURFACE DISPOSAL 1238 $45.00 ❑ SITE EVALUATION UPON REQUEST �'7349 $42.00 ❑ MULTIPLE PARCELS WITHIN SAME (NO PLOT PLAN) m LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $11.00 a. 1 at 4 Parcels (Each) 1238 $45.00 (Less than 1 year) U. b. Each Parcel after 4 7344 $16.00 ❑ PRELIMINARY ELECTIVE 7352 $45.00 W ❑ Rereview (2nd review same parcel) 7344 $16.00 EVALUATION (Attach DOH SAN 53) ❑ Site Evaluation in Conjunction with ❑ HOLDING TANK 7351 $45.00 Critical Area 7346 $86.00 ❑ ALTERNATIVE/EXPERIMENTAL 7345 $132.00 ❑ Site Evaluation Lot Less than SYSTEM 10,000 Sq. Ft. 7347 $86.00 � NITIAL DATE / Holding Tank Agreements Completed ❑ Yes - Certification of Existing S.D. System Required ❑ Yes J201 0 . WQCB Clearance required. (Attach Form ❑ Yes Z - No DOH SAN 007, Santa Ana Region Only) Socia Percolation Report Required. ❑ Yes Special Feasibility Boring Report Required. ❑ Yes No Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes Ja "0 Other ❑ Yes Staff Specialist Lot Inspection Required ❑ Yea kT No Lot Inspec Ion Date Soils boring report try Pfojeci Date n Soils Map Page Soil Type Approved by /� �-- Date _J� It I i.1 No. of Systema TJF6 of System(s)No. Dwelling Unita () (1) Septic Tank Soil Rate Grease/Sand Z Existing FeIding Tank placement g InOcp 11 Rep n� /y / W � (iH! U (2) Leach Line Sq. Ft trench fires Sidewall allowance Install.� Line(a)-- fl. long f< wide with Leach Bed sq. R ft rock/ sq. R per running ft min. inches roclt' drainlirres or om area Leachlines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Seepage Pit 7htal Depth :; /V r. Applicable Applicable I 6 Inlet (BI) J� / 7� Max. Allo le/Oepth N/A tactor O No. 2 System IQ- REMARKS: This application PPROVED IE&for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated 0 on the accompanie p o pan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the O above -designed system. No construction is permitted in the required reserved 100% expansion area. S (01 Septic, tank and sewer lines must be 50' minimum from any well 71�2�� G(�ttjd Leach lines must be 100' minimum from any wells, including expansi ar q% Seepage pits must 1�50'eminimum ny wells, includi�n%g expansion r t'r �from /�C/I/ �G [-a�Gc .. /L./-�7���-joC / Signature of Health Official Dat - Gt/axfo oL . RECEIPT NO. r 3 Y7 Issued By Date %' 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 za Building Address Tlihf " P.O. BOX 1504 APPLICATION ONLY 78-105 CALLE ESTADO Lii4.�211 A�Z%� LA QUINTA, CALIFORNIA 92253 Address t /7 City Izip ITel. Z•ZGz 1 .37—Z —lD Contractor Address Statei i City S �� & Classif. � -7. 3 43 -,-/- Lic. # Designer Address Tel. CityI Zip I State I Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am lic nsed under provisions cf Chapter 9 (commencing with Section 7000) of Division 3 of the @@usiness and Professions Cod ; and my license is in full force and effect. A/ — / v . /_../ OWNER-BINLDER 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 r/e a signed statement that he is licensed pursuant to the provisions or 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 or Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty 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 or 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 or 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 or 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 cerificate 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 thg work for which this permit is issued, I shall not employ any parson in any manner so as to become subject to the Workers' Compensation Laws of California. 11LDING: TYPE CONST. OCC. GRP. P. Number % 7 4—' // '— ®Z '7 �a !gal Description oject Description Sq. Ft. No. Size /y09 Stories New 1d Add ❑ Alter ❑ Estimated Valuation PERMIT NOTICE TO APPLICANT: If, alter mating this Certdicate of Exemption you should become Plan Chk. Dep. BY: Plan Chk. Bal. Minimum Setback Distances: Const. Mech. Electrical - Rear Setback from Rear Prop. Line Plumbing ' �' /'1'r"✓ S.M.I. I hereby affirm that there is a construction lending agency for the performance of the Grading Driveway Enc. Infrastructure Lender's 'Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. TOTAL 7 G L No. Dw. Units Repair ❑ Demolition ❑ D s" AMOUNT 3 00 .ors• o� 7 � 7O. ZJ • 00 6 7,q 3 REMARKS Clt��lfi�Iit7 _IV .L'V .7.x c ovo > ........ Date Owner NOTICE TO APPLICANT: If, alter mating this Certdicate of Exemption you should become ZONE: BY: subject to the workers' Compensatfor, provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Minimum Setback Distances: Front Setback from Center Line - Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY �+ 1 F€ ' �' /'1'r"✓ `Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (S9c. 3097, Civil Code.) Side Setback from Property Line Lender's 'Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. 7 G L I certify that I have read this application and state that the above information Is correct. Issued by: Date Permit 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. Validated by: Signature of applicant Date Mailing Address Validation: City, State, Zip BUILDING DIVISION CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SQ. FT. ® $ UNITS • ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. FORMS SEWER OR SEPTIC TANK ROUGH WIRING MOBILEHOME SVC. BAR SINK FOR. SQ. FT. ® GAS (ROUGH) METER LOOP GAR. SQ. FT. ® POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CAR P. I SO. FT. ® I WATER HEATER WALL SQ. FT. FINAL INSP. DRINKING FOUNTAIN SQ FT ® WATER SYSTEM URINAL ESTIMATED CONSTRUCTION VALUATION $ _$ WATER PIPING NOTE: Not to be used as property tax valuation FINAL INSP. FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED VENTILATION LAUNDRYTRAY AIR HANDLING UNIT CFM FIRE ZONE ROOFING 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 LATHING 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 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 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 INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL OIIICE OF AGRICULTURAL C0"IMISSIONER AN D WEIGHTS & MEASURES 49-613 Ilwy 86, Suite D-12 'Coachella, CA 92236 619-342-8291 E. LEON SPAUGY Commis-IO`.EA LAMES O WALLACE ASSIVANI r7u��iSS�U�EP. CLEMENT BE`VENISIE SLALEA DATE / I _� 7-- '<' CASE N0. Itv !W1K S l� / 7 DEVELOPER'S NAME: S T R R R ADDRESS, PALM SQA''IAJ&S dl? 917,24,2-, TELUNIONEs Z24,2— TELUNIONEs (G/q) 32 2 DoT �� /3Lk z _33 Dear Developer:7 '7'74 -Z. .Z After reviewing your landscaping plans, all plana material listed is not in violation of quarantine laws governing the Coachella Valley. If substitutions do occur and they differ frufn plant n>aterial listed, this office must be notified immediately. Thank you for protecting and preserving the Coachella Valley's pest -Free environment. I Agricultural Cctmtissiol is 011ke cc: Indio and Riverside office "�•Jm+a`�rir�'"+^.�_",..�.�.'s� x�ja�� iti`E l'7���»' i �"��r-v.'"y;-:h�?�9y;�q!:¢+`Y a`�'t�,-"�^C" C'Xab.'v�p'ti'..a:°"• ai:-"'eY71�+rt- •;^: -•y_-.�.,�9C�'1`T.i*'%`DF�='�i r w r+� I �i r Z 0 W 0) M U Z O U W 0 Ss/ 1 COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No. 77i ENVIRONMENTAL HEALTH SERVICES 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 speculations as indicated on the attached checklist. 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. VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG' Agent, Contractor, Contact Person Phone Address & Phone -')7 wIZ.fi? e- l A).5 r-4tzeTio 3 Z z-10 ZA Owner Phone Mailing Address *6 A-7 A Z State Zip Job Property AddressaWe,1 ,G4 Legal Description Prop. (PM, Tract, Lot) �1L1'lf SPe",k1Gs /4 2 - e -SC?, XZ4.4l17 Xo r/i •(j4/1 2,3 Lot Size / ate Ar g nc fr Use of Permit P/P, CU, etc. t A QNr A✓7-A Other /aj V44 W Czxf' Sam -fes_ _ 6G G� � ��S 7_A /d / ellingrfvlH Snell/P: ett Date Signature of Applicant CATEGORY: REV CODE FEE SUBSURFACE DISPOSAL 1238 $45.00 CATEGORY: REV CODE FEE ❑ SITE EVALUATION UPON REQUEST 7349 $42.00 ❑ MULTIPLE PARCELS WITHIN SAME (NO PLOT PLAN) LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $11.00 a. 1 st 4 Parcels (Each) 1238 $45.00 (Less than 1 year) b. Each Parcel after 4 7344 $16.00 ❑ PRELIMINARY ELECTIVE 7352 $45.00 ❑ Rereview (2nd review same parcel) 7344 $16.00 EVALUATION (Attach DOH SAN 53) ❑ She Evaluation in Conjunction with ❑ HOLDING TANK 7351 $45.00 Critical Area 7346 $86.00 ❑ ALTERNATIVE/EXPERIMENTAL 7345 $13200 ❑ Site Evaluation Lot Less than SYSTEM 10,000 Sq. Ft. 7347 $86.00 INITIAL DATE Holding Tank Agreements Completed ❑ Yes rNo Certification of Existing S.D. System Required ❑Yes o j WQCB Clearance required. (Attach Form ❑ Yes -Nk] o DOH SAN 007, Santa Ana Region Only) Socia Percolation Report Required. ❑ Yes f,/� Special Feasibility Boring Report Required. ❑ Yes g,No_ Detailed Contour Piot Plans Required (1 to 5 ft. interval) ❑ Yes NNo� Other ❑ Yes E3 Staff Specialist Lot inspection Required ❑ Yes No Lot Inspection Date Soils boring report by' Project # Date p / �u C'' Z� �� 7 —!J Soils Map Page Soli Type Approved by /Date No. of Systems i( T16 of Systems) t0 Fi�lding Tank ntaoement No. Dwelling Units 0 (1) Septic Tank Soil Rate Grease/Sand ❑ Rep Gal7 —!7Gal a(2) Mach Una Sq. Ft Sidewall allowance Install Une(s) It long wide with �LeLeach Bed sq. It. trench area ft rock/ sq• ft min. inches rock to v grainy ines or 6'boftom area per running ft Leachlines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Seepage Pit TBtal Depth / Other. Appl e — mrS" / 6 r Inlet (BI) / ��A Max. Allowable Depth N/A ♦/ Overburden facto No. 2 System N/A- REMARKS: Yr✓LC,+ e1%� tn- GL -, ��,. ILC.z7/G,?v . ,melt eC� Gv�e.n.r U This application PPROVED� NIE04or the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompanied p o pan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the above -designed system. No construction is permitted in the required reserved 10046 expansion area. (1 Septic tank and sewer lines must be 50' minimum from any wells / �"�-��� S^ '"' Gc/Lttfl.ia _ ( Leach lines must be 100' minimum from any wells, including expansion area 7 ( Seepage pits must ber150' minimum from any wells, including expansion area �L� �f s �� Si nature of Health Official "�� `� 00 Date RECEIPT NO. V-3 Y7 Issued By� Date 7 DISTRICT: ❑ Riverside, 01rhdio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑. Blythe DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant' PINK - Bldg. Dept GOLDENROD - Plans/Records