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10366 (PLBG)4 C-_ No. 10356 P.O. BOX 1504 Building 78-105 CALLE ESTADO Address 49845 Coachella Drive LA QUINTA, CALIFORNIA 92253 Owner Cam BUILDING: TYPE CONST. OCC: GRP. —William, Mailing Address Same A.P. Number , City Zip Tel. LaQuinta 92253 Legal Description Project Description Install Seepage Pit Contractor iendxic Dbon ConstruCction Addre468315 gieley -Rd City eat city Zip 9223418-1747 Te .: State Lic. City & Classif. A 256184 Lic. # 194 Sq. Ft. No. No. Dw. Size Stories Units Arch., Engr., Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. City Zip State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed underprovisions of Chapter 9 (commencing with Section 1�177f000) of Division 3 of the Business and (Pfbfessions Code, and my license is 7)'n full/force and f /. feC 4.R �?A'�a.,d"" 4+d 4"'.. 1 i! J;� 1/. 1�I' i* SIGNATURE' OWNER -BUILDER DECLARATION 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 Me 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 or not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will .V do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and .Z^'-;Professions Code: The Contractor's License Law does not apply to an owner of property who 'buflds 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.) - Estimated Valuation �' Q�Q f PERMIT AMOUNT Plan plan Chk. De Plan Chk. Bal. Const. 45.00 Mech. Electrical ' Plumbing ❑ I, as owner of the property, am exclusively contracting with licensed contractors to torr 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.) ❑ I am exempt under Sec. B. R P.C. for this reason S.M.I. - .d 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, ora certified copy thereof..(Sec..3800, Labor Code.). Policy No. company .8 Copy is filed with the city. ❑ Certified copy is hereby furnished. TOTAL 45.20 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (8100) 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, alter 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 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 Issued by: Date Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. ® $ UNITS COLL. AREA SLAB GRADE YARD SPKLR SYSTEM 2ND FL SO. FT. HEATING (ROUGH) STORAGE TANK POR. SO. FT. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS . CAR P. Q. FI. DRAINAGE PIPING WALL SO. FT. HEATING (FINAL) DRINKING FOUNTAIN. SO FT ® URINAL ESTIMATED CONSTRUCTION VALUATION $ 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 GRADING CU. yd. $ plus x$ GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY AIR HANDLING UNIT CFM FINAL INSP. KITCHEN SINK ABSORPTION SYSTEM B.-T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE,TEMIPERM LAVATORY i HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER. B.T.U. SO. FT. ® c BATH TUB FIRE ZONE ROOFING: SO. FT. ® c WATER HEATER MAX HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1% c SEWAGE DISPOSAL SO.FT.GAR ® 3yec HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PLCK.FEE OONST. 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/41, 4 ROUGH WIRING. DUCT WORK ROCK STORAGE ' FOUND. 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 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 rj 1►3 D 7 S _ o .� �� 1411� ea t c l -I -k- (�l. ti !p V- HENDRICKSON CONSTRUCTION, INC. General Engineering Contractor o Underground Specialists V7o �-- �" � o lot,'✓' �v Y1r�5� j✓5 /I Doo 9nY(-t ca�,c. 7-0-1-)l Post Office Box U o Cathedral City, CA 92234 ® (619) 328-1747 License 11256184-A RIVERDIDE COUNTY DEPARTMOrb OF PUBL90 HMLTH 0 W lul! 8362H @F E 0 V 5 P. 0 N M ENr 7, A L 0 112ZA LT H FcuO Eszsb-16sImmat I X - Sewago Disposal Tr,21,Pcr Pam E S,Pzic Tarh Al A, V.zY-r'l Sq. R. 0 Le2f.;h Line Pit if , zv\!Zr NO, 011-,�fttj so -wage disposal -"-ZJ Alf Z-v"Ingo- P rr. Cod �jf)m,�a` lia;Ium fu Nng e. v0t,;ng e;,in C-:;rizal approval. _' 6 Dav,;r�A F A-,,- inat3l!ation of the sewage This; is to co"Zily V-,f,t the. FR•W�r3kn i.-7 occupancy, construction )r mtaftIm'. the itsin(s), &.echati abo-vo,. 91 13 H U W U) W Z O H U W X Z O U W Cn W Z O U W N COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No. ENVIRONMENTAL SERVICES DIVISION 617 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 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. ap licgtion shall remain valid for a period not to exceed one year from date of approval. v� f thit�-,ii aac�:�Sg.�g ?&bG # I VERIFY ITEMS IN SECTION A FROM A NON-FEE.BUILDING & SAFETY (goldenrod) APPLICATION Agent, ContractooNntact Person Phone Address City State Zip iter Phone Address City State Zip Job Property Address City �t StateZip Legal Description Prop. (PM, Tract, Lot) Lot Size Water Agency/Well Use of PIP, CU, etc. Other e (1) A --Permit ` Owelling,/MH Site Prep, etc. A Signature of Applicant Date CATEGORY REV CODE FEE CATEGORY REV CODE FEE SUBSURFACE DISPOSAL (per system) 1238 $153.00) ❑ SITE EVALUATION UPON REQUEST 7349 $120.00 (NO PLOT PLAN) ❑ MULTIPLE PARCELS WITHIN SAME LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $ 58.00 a. 1st 4 Parcels (Each) 1238 $153.00 ❑ PRELIMINARY ELECTIVE EVALUATION b. Each Parcel after 4 7344 $ 55.00 (Attach DOH -SAN -53) 7352 $ 69.00 ❑ REREVIEW (2nd review same parcel) "7a 7344 $ 55.00 ❑ HOLDING TANK 7351 $119.00 ❑ SITE EVALUATION in Conjuction with Critical Area 7346 $197.00 ❑ ALTERNATIVE EXPERIMENTAL SYSTEM 7345 $656.00 ❑ GRADING PLAN REVIEW DETAILED 1238 $104.00 ❑ SITE EVALUATION Lot Less than 10,000,Sq. Ft. 7347 $172.00 ❑ GRADING PLAN REVIEW CURSORY 1238 $ 55.00 ❑ SECOND FIELD VISIT (SITE EVALUATION) 7346 $ 85.00 ❑ COPIES (LAND USE) 7786-81 $ .50 DATE INITIAL ZC4� Holding Tank Agreements Completed ❑ Yes ❑ No Certification of Existing S.D. System Required ❑ Yes ❑ No i f WQCB Clearance Required ❑ Yes ❑ No t (Attach Form DOH SAN 007, Santa Ana Region Only) j Soils Percolation Report Required ❑ Yes ❑ No Special Feasibility Boring Report Required ❑ Yes ❑ No I Detailed Contour Plot Plans Required (1 to 5 ft. interval) ❑ Yes ❑ No Grading Handout Provided ❑ Yes ❑ No i Staff Specialist Lot Inspection Required ❑ Yes ❑ No Maintenance Booklet Provided ❑ Yes ❑ No Lot Inspection Date Initials C/42 / Soils Percolation Boring Report by Lic/Project # Date Soils Map Page Soil Type Approved By Date No. of Systems Type of System(s) No. Dwelling Units (1) Septic Tank Soil Rate Grease/Sand ❑ Holding Tank ❑ Replacement Bedrooms, Fixture Units t S �" k- Greaselntcp/Lint Trap ❑New gAddition 0 ❑ Existing �ycfrrUow� /ODU Gal. Gal. Sq. Ft. Total Linear Sidewall Allowance Leach Bed sq. ft. Bottom Area Ft. ft. rocW sq. ft. per running ft. Install Line(s) ft. long ft. wide with of Bottom Area Inlet Tested Depth O NA min. inches rock below drainlines or Proposed Bottom Tested Depth Leachlines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet Seepage Pit Total Depth (TD) I Other: Applicable j �,r ,S (BI) ,C� , / Max. Allowable Depth `7/r 5' N/A Overburden Factor ❑ 5 6 ) ? / Well Review Approved: Signature Date Well Drilling Permit # Grading Plan Approved: Signature Date REMARKS: ©a'a�w'e e f f" jr._ c:-._•/ n ea aJ This application is APPROVED/DENIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompanied plot plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the above -designed system. No ronc ruction is permitted in the required reserved 100% expansion area. (1) Septic tank must be 100' minimum from any wells ('2n) Leach lines must be 100' minimum from any wells, including expansion area /d3)] Seepage pits must be,150' minimum from any wells, including expansion area Signature of Health Official --tel - hl+✓��� icer �� Data /1 - 9 (`� '" i ❑ CASH ❑ CHECK NO. 5A RECEIPT NO. / a 7 Issued By Date_ / DISTRICT: ❑ Riverside A Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe DOH -SAN -122 (Rev6/91) DISTRIBUTION: WHITE-40r1fice file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—PlanslRecords i 3ff