0104-068 (PLBG)LICENSED CONTRACTOR 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 my License is in full force and effect.
License # Lic. Class Exp. Date
Date .f 4 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S 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 & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 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, and agree that if I sho
subject to the workers' compensation provisions of Section 3700 Labor
Code, I shall forthwith comply with those pr?vi ions. 1
Date: Applicant ""
Warning: Failure to secure Workers' Compensation coverage is u wful and A
shall subject an employer to criminal penalties and civil fines up to 1 00 , in
addition to the cost of compensation, damages as provided for in S ction 706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set fo
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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quints, its officers, agents and employees.
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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspection purposes.
Signature (Owner/Agent) f� M �i..x Ln Date "
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS Ni
OWNER CONTRACTOR / DESIGNER / ENGINEER
LA. QVI&TA (!A
USE OF PERMIT
#d.Y-4 1 E&FP,VI.OF PIT
'1fAl.rVA` ION
1310s 0A L11
P1.:1,fM71)1700 "K -I lip"W I0 1-i3t10-419-(K)0 MAI
g 2001
CITY OF LA QUINTA
FINANCE DEPT
11
9L1"&W4TAL. CN-MIS"iRU(MON I�3�') 111L,A,N" f`131 .`Y,
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
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POUN?Y OF RIVERSIDE HEALTH SERVICES AGENCY ASSESSOR'S PARCEL NUMBER
DEPARTMENT OF ENVIRONMENTAL 4q4-130 — O/ R
HEALTH
APPLICATION FOR WASTE WATER DISPOSAL APPROVAL
APPLICANT: Submit this form with four copies of a SCALED plot plan (1"=20' to 1"=40' SCALE) drawn to County specifications as indicated on the attached
check list. A non-refundable filing fee 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 payment.
�
LOS -e E(T V Cf- l A W u,,A• r4
Agent, Contractor, Contact Person
Address City State Zip
Telephone
SCh 3 Z m owyrwig CA 9.'z..3
'?wr?' s
Owner
Address City State Zip
Telephone
Q
YI-720 Y"111,00 1.40 c . X72s3
OJob
Property Address
y8��b sAN i s �4�o S7'/
City
fA 9�3�
Zip
e) -I ,s�
U
LU
Lot Size I
��t' x }c
Q ter A enc Ise of Permit, P/P, SUP, PUP, etc.
4�# tc� <<�y QED F Pyr 7b EXir r,
Legal Description y
t�= s� 9, I A G,�rv�n
DBA
CJ14 /f,.7 .1,1! f rX I(7� D 4 Ilin y Z _.
Si�jtWteA' I '� 1 J y sr1NG
Date , 1
FOR OFFICE
USE ONLY
CHECK BOX IF REQUIRED
If any box is checked, this application shall be considered rejected until the
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
information is provided and the fee paid. Resubmittals later than 90 days
after date noted below may require repayment of fees.
❑ Other
❑ Staff Specialist Lot Inspection Required
Z❑
Holding Tank Agreements Completed
❑ Certification of Existing S.D. System Required
Thomas Bros. Page Grid
LULJWQCB
Clearance Required
❑ Date Lot Inspection Completed: Initials
U)
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required
❑ Final Inspection by Department of Environmental Health is required.
❑ Rereview Required Initials Date
Please call 24 hours PRIOR to inspection.
e�rf7-C/42 Report By Zaryry t%/'1 i4A+VT16 rA*� Lic/RojeG.# 39oL�0 Date
Soils Map Page Soil Type Approved By Date
No. of Systpms
EX/f77�✓i6
Type of System(s)
No. Dwelling Units t M44
(1) Septic Tank
Soil Rate
Grease, Sand
(J Ho Tank ❑ Ijgplacem;ntBedrooms,
❑ raw ddit�r'stel,
Fixi e l ait�
�X/5�71✓
ves � ,, , e
f�0
p, '•�
Grease Pte Lint Trap
x sting ❑ Conn�c tiro Se
(� Gal.
,
.� Gal.
Sq. Ft.
om Area
To inear
Ft.
Sidewall Allowance
ft. rock/ sq. ft. running ft.
�~ rw
Install Line(s) ft. long ft. wide
I%ach Bed sq. ft.
of om Area
Inlet Teste th ❑ N/A
Proposed Bottom Tested Depth
with min. inches rock below drainlines
U
or
Z
0
Leac lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (131)
Seepage Pit
Maximum
G er:
~
Applicab
/I
d 1071-4
D
t
Total Depth
f
Allowable
Depth
W
N/A Overb en Factor
�/
111 JJJ 6'
=
r�. E,r
�•
r. , ' 6ro" , CA
n
TD Y3
�
Well Review Approved: (To &144W IDate: Well Drilling Permit#
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Plan Check Only Approved: Date:
REMARKS:
i'
0�) 1(x 1
3
applrc ionr ss�AEDIED-h,- trlw
D
�
�w'oThis
'(� �B above, regar I g e design of a disposal system as indicated
on the accompanied plot plan, using the requirements set forth in SECTION
S� 1 / 1 j
3
C above. A building permit is necessary for the installation of the above-
Revenue Code / Fee $
designed system. No construction is permitted in the required reserved
100% expansion area
Check #
(1) Septic Tank must be 100' minimum from any wells.
Z
(2) Leach lines must be 100' minimum from any wells, including expansion
Date � "� Q � Initial
0
area.
C' .,e. T•
(~j(3
Sewer lines must be 50' minimum from any wells.
U)
rt e
(4) Seepage pits must be 150' minimum from any wells, including expansion
RIVERSIDE: 909-955-3980
area.,V /V .,.L�/I6�� Tftrf% 4 IW4 77
INDIO: ��' 760-863-7000
SOUTHWEST: 909-600-6180
Signature /
Date
UtH-SAN-1ZZ (Rev 1U/uu) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDEN ROD—TPlans/Records
�'' • ♦.�^ �''.'r,f..,..y�•.?t•" ^+"""^",.>V•'r+�., a,-,�.,.a b..+r . � "c-:A�.: y.'.,ya•'a^'..+e'�..« � �4x�"";4`";�''i .r.%;�: ♦ �}?"i"+.'tsar,� y`e-'may. � .J ` � i�4. r ;..e�3;+.:ri.F: rt -.y r r+
A
County of Riverside Health Services Agency i
Department of Environmental Health
4080 Lemon Street, -2nd Floor ,
P.O. Box 1206
Riverside, CA 92502 RED APR 3'y:2'001� ��•
;y Y r
ATTN: Land Use Section A
T
1. Certification of Existing Subsurface Sewage Disposal System. : Date of Inspection: '39-0
(Property
q1 1A
/f4 M 11A Al
(0wner's Name)
(LeDescription and APNI,
FAILURE'TO PROVIDE ALL REQUIRED INFORMATION SHALL PREVENT
OWNER FROM OBTAINING ENVIRONMENTAL HEALTH SERVICES APPROVAL.
2. 'SI16 design and location (11- 201, maximum scale) of the sewage d sposal system in relation to attached dwellings,
structures,,wells, etc. on required plot plan (see Item 11 of memo RE: Existing Subsurface Sewage Disposal).
3. a. I. examined the a sting subsurface sewage disposal system at the above location on (date) 0/
date and determined that the septic tank capacity, is gallons and that there is sq. ft.
of leachline bottom area. There are 7 'bedrooms in the dwelling..
b. !There are leachline(s),- each ft. long.
c. There are hn/r seepage pi""' each in diameter, !Sr ft. deep.
d. The leachbed, is ft. by f ' total sq. ft.;' of leachbed area.
4. a. Construction of septic tank (please check one of the following):
aconcrete ❑ fiberglass ❑ steel `
❑ other (explain):
b. Internal dimensions of septic (length 7, 5' ft., width ,�'p - depth 714 ft.)
C. Condition of tank (please answer yes or no for each question):
Yes No
Inlet Tee present? p- ❑
Outlet Tee Present? `
Two compartments?
Tank structure deteriorated?* ❑ Ca' If yes, briefly explain and indicate appropriate correction suggested:
d. Condition of D -Box (if needed) Level ❑ Yes ❑ No. replaced ❑ Yes. C3 No NA �-
full of septic effluent ❑ Yes ❑ No . -.
'5. a. } While pumping the tank, did effluent flow back into Tank from the absorption system?es ❑ No
b.' -Prior to pumping, was the liquid level in the tank ove the outlet tee? ❑ Yes &No,�
C. Was the area around the lids oxidizeo.? ❑ Yes RNo` ,
? d. Is design df system gravity feed? &Yes ❑ No
e. Were wells) observed on this or adjacent property? ❑ Yes 2No .
If yes, indicate distance of well from: Septic Tank
Leachlines ..-
�' Seepage Pits
f. Distance from springs, lakes Septic Tanks
and natural drainage courses: Leachlines ft.
(circle appropriate item) Seepage Pits
gig. Sewer is within 200 ft. of system and abuts property line. ❑ Yes @"No
ADDITIONAL COMMENTS:
h. How long has dwelling been vacant? (if applicable) months weeks N/A Q,
6. It is my opinion that the system appears to be in good working order and can be expected to function properly with
proper maintenance. ❑ Yes RNo
' -1r _ -�..�. �� y+-� .,-��. - .. �•'uµ w.++.�r �+.� .._. i }'.v"!- .,lwr-. +. ':�'ajh, `y- -�J,.: J... --� �•'
if there are any further questions, feel free to contact the undersigned at' F
LA rA- 9
Telephone Number Addreis
I c rtify unVer pen ,Ity of erjury that the foregoing is true and correct:
Zure C•42 State License Number
/3E4T �t GE►E
Print Name
Expiration Date
Name of Pumper Company and Receipt Number/Name of Company Holding Cf42 License
/50 30 S� laiclllgla !>� r�ollG lF� ra. G�
Address
.Date .
DE14-SAN•184 (Rev 12/97)DISTRIBUTIOW-WHITE—Office; PINK—Contractor; YELLOW—Applicant
v T�
0011i' f •rY O ii f4.j.: RSiDE HIF t_I.� c r':.-3\'el, r`
Fnnrf 6tiSc
Disposal I�E4T�t/ED5 f
ira,iei Park EXISf.Gal.,Sep;ic rangy C/.rde 04c) r" AOCM40
_ Mctel, fat., Hotel Sq. Ft: f Le,3ch J.ine �
• Dwaliing irwk-extr) P
__Cornrnercial Building�3e Ap���Con tion �__
t wo_( TD�e P4 I;V MD Seepage Z12/ES W�
Swimming
Pool. Connect to Existing S.S.D.S. -5iQEA C
2—(No on-site regenerating water softening devL-es may be discharged into the individual sewage disposal P/r (To /i�ivwi,.i
system herewith approved without clsarancc the Water (tea i ontrol Board..
Water sup�,h/ sFr i /this �nst jllation must r✓c from an a ro u�ce
All sewage,(, i> ���f' , �.}} t pp �,�/I%/ i16 (C l/(NQ )
} - ir�r�it1ian must conform with requin! sof current Uniform Plumbing Cod,
Any cutting, gradinclor filing in excess of two(2) feet will nullity sewage disposal approval.
Approval has been obtained from the Regional Water Quality Control Board for installation of the sewage
disposal system. .
This is to certify that the Riverside County Environmental Health Se' s approves the subsurface sewage
disposal plot//plan to obtain building permit for ' alatloh, co/nstr/ucti
BY
iAAINTAIN 100% EXPANSION AREA. MIN. .__FROANY WELL
MIN. 110' FROM ANY E TREE OR WATER MA KN Xv /-te,.d ..'
�� �' ! l/ y ��G C��j ��`'i /�iLc-�Li� 7�" f2•Q`�.�G�? G7�
k1d %[✓
AP BY TH
r
MENT OF PUBLIC NEAT •Asir m oftbeee pigas bytaeDspameatatr�IBglth of Riverside County doss not relieve the fir.D FOR ONE (1) YEAR Nr or Architect of the responsibility for � y�yM•ATE OF APPROVAL �` °r "r°b't�"t°r`'
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