0008-326 (DSF)LICENSED CONTRACTOR DECLARATION
6'hereby affirm under penalty of perjury that I am licensed under provisions of
CF1ap�oi r 9 (cornm'encing 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
5097 r ,,� ��. 07/3)/2(Dated�•�' Signature of Cop cta�"��—
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 & 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.
J.,)4 1 have and will maintain workers' compensation insurance, as required by
Serftion 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 STATR FU14D Policy No. 229.09-000"16
(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 should become
subject to the workers' compensation ovisions of Section 3700 -of the Labor
Code, I hal I Toth comply w�ith'fPose proyis�
Date: ?' Applic nt /i,� -�"' }!°'�• -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $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.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
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 Quinta, 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 (Owned, e.t)`r�% � - Dati
BUILDING PERMIT PERMIT#
DATE" / jVALUATION LOT LMS -36 TRACT
(�j''� ;� U,tIlItD W 149
JOB SITE
APN
ADDRESS 491-160 AVENWA FE NAMO
08_20)_016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S:B'EiUM 1HORNBF-AK
P-WCHO C;ARISTRMO DEVM, (YPME-1rt'
45-700 SAN DndM
79687 COUNTRY CLUB DR 0203
1A QUWA CA 92253
T3E1 MUDA:DINESS C,A. 92201
(760)345.77:55 C-SLO 1%9
USE OF PERMIT
DEMOLTMON
DEMOLITION OF RXIS`PI'NG BUILDING 3000 S.F. ONLY
M
VALUA!'IOt4 1061300M FSS
.
1
RIIXIM. "COSTOFCoNg'r'RUC:710H
100)0.13D
FI+ IMAM W SUMMARY
DEMOLITION FEE 101.000.423-000 55:00
t p' 'An:
cw
.
a.
P 1,
AUG 2 2 2000
NTY Or LAUINT
i
ffOIB-T'Ci'JCAL COAdil`XWIC-110N AtM PLM (21E CK
$45,00
LEE PPX� ,PMD VUS
`fi0.00
TOTAL I'Jk�� F"05 DVE NOW
RECEIPT
DATE
BYf {Z
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
glab•Grade
Return Air
Steel'.'
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Finale=`
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cotter
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Recording Requested BY
First American Title Company DOC N 2000-107604
RECORDING RZQV9ST8D BY
page I of I Do* T Tax Paid
In Offiolat ftsardo
C&jnty of Riverside
AM WMN RECORDED MAIL TO Gary L. Oriats
SHSRrAN H. HORNBEAK County Clark
P. O. BOX 1848 ff I!i I1!f 1! f `
La ouinta, Ca 92253
111111 Bit.
s I U 0 F*41 i ttaa ft
A.P.N.:QWS2-007 TFLA#:C>76 0
GRANT DEED
Q Mill UNDERSIONE) ORANTOR(a DECLARE(a)THAT DOCUMENTARY TRANSFER
TAX 35: COUNTY $412.50
X I computed on full value of property conveyed, or
ont value c puted on full value less v ue of liens or encumbrances remaining at time of sale,
unmoorporated area; j X I City of AA Ouinta , and
f
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged.
fJ Jack Goodman, a WIdower
hereby GRANT(S) 0HERZAN
Hombeak, a married woman, as her sole and separate vroperty
the following described property in the City of LA Quints, County of Riverside State of California;
W 149 of LA Quints Golf Estates 01, In the City of La Quinta, County of Riverside, as per map recorded in Book
37, Page(s) % to 98, in the Office of the County Recorder of said County.
man
-A
Document Date•. April S. 2000
STATE OF CA )SS
COUNTYOF LD'OW'Ierside
On April 5, 2000 heroic fric. Lena A. Ellerbroek
-J.
personally appeared
Jack Goodman --------------------------------
pericinany known so me (or pinved in rase on the basis of utisfoct"ry evidence) to be doe persorK of whow ns-�* I alwouhsicnhed in the within Insentriterst
and acknowledsed to me a-seAlwy executed the urne authorized capecity4ie" and that it sISPAW114400- M the Ing wmu
do persovM or dic entity uponhalfof which the perwr4s) acted. executed the lastryment.
WITNESS my hand and offici&I seat.
aLERBRM
ja4A
nit area for offictil nwanst sell.
A.
r
Mail Tax Statements to: SAME AS ABOVE or Address Noted Below
AQMD SOUTH CO. T AIR QUALITY MANAGEMENT,' STRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
MAIL ORIGINAL TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE #55641, LOS ANGELES, CA 90074-5641
AQMD USE ONLY
SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION #
COMPLETED BY MYRNA COMPANY BRICKLEY ENVIRONMENTAL PHONE 909-888-2010
DATE 08-01-00 CHECK # I
%, j FEE $ 82.42 PROJECT # 32T2
NOTIFICATION TYPE
Original Revision Dates Revision Other (highlight) Cancellation
PROJECT TYPE
Demolition Ordered Demolition Renovation (removal) mergency Removal Planned Reno (annual)
SITE INFORMATION
SITE NAME VACANT RESIDENCE
SITE ADDRESS 49-160 AVENIDA FERNANDO CROSS STREET EISENWOER ST.
CITY LA QUINTA STATE CA ZIP COUNTY RIVERSIDE
DESCRIBE WORK LOCATION THROUGHOUT THE HOUSE
BUILDING SIZE (SQ. FT.) 3,000 NUMBER OF FLOORS 1 BUILDING AGE (YEARS) 30 NO. OF DWELLING UNITS 1
BLGS PRIOR / PRESENT USE
Commercial Hospital Industrial Other Office Public Bldg Eesid:e::qc� School Ship Unv/College
SITE OWNER SHARON HORNBEAK ADDRESS P.O. BOX 980
CITY LA QUINTA STATE CA ZIP 92253 CONTACT AIMEE GRANA PHONE 760-345-7755
REQUIRED BUILDING
INFORMATION
ASBESTO� NO
PRESENT
ASBESTO YE NO
SURVEY?
ASBESTOS YES NO
REMOVED?
BLDG TO BE YES NO
DEMOLISHED?
PROJECT DATES
START 08-21-00 END 08-22-00 WORK SHI
ASBESTOS AMOUNT TO BE
REMOVED (in square feet)
FRIABLE
2310
CLASS 1
25
CLASS II
TOTAL REMOVED (ADD ROW)
2335
ASBESTOS REMOVED FROM
FACES PIPES COMPONENTS
ACOUSTICAL CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING STUCCO MASTIC
2,100 200 10
DESCRIBE TYPE & AMOUNT OF
ASBESTOS (in square feet)
FLOOR TILE (VAT)
DRY WALL
PLASTER
TRANSITE
25
ROOFING
OTHER (DESCRIBE)
CONTRACTOR INFORMATION
CSLB LICENSE # 610414 OSHA REG # 49 AQMD ID # 76397
NAME BRICKLEY ENVIRONMENTAL ADDRESS 957 WEST REECE STREET
CITY SAN BERNARDINO STATE CA ZIP 92411 SITE SUPVR BRICKLEY / DARST / GOMEZ PHONE 909-888-2010
LARGENT/CLONINGER/CRUZ
WASTE TRANSPORTER #1 BRICKLEY ENVIRONMENTAL
LANDFILL AZUSA LAND RECLAMATION CO.
ADDRESS 957 WEST REECE STREET
ADDRESS 201 GLADSTONE AVE
CITY SAN BERNARDINO STATE CA ZIP 92411
CITY AZUSA STATE CA ZIP 91702
Asbestos demolition/Renovation Notification Form REV 990601
Forms, instructions and the Rule 1403 can be obtained from AQMD web site hfp://www.agmd.gov Page 1 of 2
CAL/OSHA ASBESTOS NOTIFICATION
BRICKLEY ENVIRONMENTAL
957 WEST REECE STREET
SAN BERNARDINO, CA 92411
TEL: (909) 888-2010 FAX: (909) 381-3433
CAL/OSHA
DEPT. OF INDUSTRIAL RELATIONS
ADDRESS: SAN BERNARDINO DIST. OFFICE
464 WEST 4"' ST., # 332
SAN BERNARDINO, CA 92401
DATE: 08-01-00
LICENSE NO. 610414
ASBESTOS CERT. A-6005
DOSH REGISTRATION #49
JOB # 3272
NAME / ADDRESS OF EMPLOYER: RANCHO CAPISTRANO DEVELOPMENT
P.O. BOX 980
LA QUINTA, CA 92253
ADDRESS OF JOB SITE:
NEAREST CROSS STREET:
VACANT RESIDENCE
49-160 AVENIDA FERNANDO
LA QUINTA, CA
EISENHOWER ST.
NAME OF CERTIFIED SUPERVISOR: CLONINGERBRICKLEY/DARST/LARGENT/CRUZBOYT
NAME OF QUALIFIED PERSON IN CHARGE OF AIR MONITORING, LAB WORK AND
RESPIRATORS: AS ABOVE AND GEM SERVICES OR CONTRACTED C.A.C. / I.H.
JOB START DATE: 8-21-00 JOB COMPLETION DATE: 08-22-00
DESCRIBE SCOPE OF JOB AND WORK PRACTICES (Inc. sq, ft.): SCRAPE AND REMOVE WET IN
SECTIONS AND DISPOSE OF APPROXIMATELY 2,100 SQ. FT. OF ACOUSTIC CEILINGS, 200 SQ. FT.
LINOLEUM, 10 SQ. FT. OF INSULATION & 25 SQ. FT. OF TRANSITE.
ESTIMATED NUMBER OF EMPLOYEES ON JOB: 6-10
EVALUATION OF POTENTIAL FOR EXPOSURE: MINIMAL EXPOSURE - RESPIRATORS AND
PROTECTIVE CLOTHING WORN THROUGHOUT PROJECT.
TRANSPORTED BY:
BRICKLEY ENVIRONMENTAL
U.S.E.P.A. # CAR 000053173
STATE HAULER #2599
AND/OR
ECTI
P.O. BOX 7318
SAN BERNARDINO, CA 92411
STATE HAULER # 3731
DUMP SITE: AZUSA LAND RECLAMATION CO.
1201 W. GLADSTONE STREET
AZUSA, CA 91702
CAD009007626
RANCHO CAPISTRANO DEVELOPMENT - SPR / 49-610 AVENIDA FEBNAINADC
0
NO. 01024
ENVIRONMENTAL P.O. Boz 1318 Phone (800) 664-1113
CT -San Bernardino, CA 92411 fax (909) 884.3144 JOB 1 3272
NON -HAZARDOUS WASTE DATA FORM
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ADDRESS E 0 BOS S$n NO.
CITY, STATE, ZIP I -A nU:r=A _ CA 9US3 PHONE NO.(7ran) 345,,55
TYPE:
CONTAINERS: No. �/ VOLUME/CY jj WEIGHT/TONS
❑ TANK DUMP
TRUCK TRUCK E] DRUMS ❑(li_i_lll'i'.'C,i))t4=.!INi`i
CARTONS OTHER
1-4014 f -F F-'1AHf._E 6;tS �E:S i liC
WASTE DESCRIPTION
COMPONENTS OF WASTE PPM %
OWWO(Ol"o of
2. TPANICTTR _
itl=.i fOtlHi..
GENERATING PROCESS
COMPONENTS OF WASTE PPM %
3.
VOC•OVA READINGS CONSTR. DEBRIS
[SITE VERIFICATION
PROPERTIES: pH ❑ SOLID ❑ LIQUID ❑ SLUDGE ❑ SLURRY ❑ OTHER
. r
HANDLING INSTRUCTIONS'USE' IDF' PK) PEP RESPIRAT01F.- �.Csl„IIPI.1E.NT `
THE GENERATOR CERTIFIES THAT THE
WASTE AS DESCRIBED IS 100% NOW
HAZARDOUS
hAd1USIraTcFr;;%; =LA cacir_KIAn10
Q
OLD/NEW
EPA
LU
I;R ICKLEy F iil�� i. i't�11�IhlEPi i tai-
_
I Q. u fs I 9 a I
C/O
NAME
ADDRESS 957 W. 'REEL_:' 5Tr:: -E t
SERVICE ORDER NO.
N~'
CITY STATE, ZIP—SAN BE RNkkT? T jhiCl. CA 'D2.41 1
PICK UP DATE
Z
PHONE NO1422- 8e'. -chits
TYPEUOR 0RINTED RR40tWE & SIGNA FIE''
H
TRUCK, UNIT, I.D. NO.
m
EPA
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NAME k C. I
NO. AlR 1 0 10 100
ADDRESS ?'�:: i). QEF=�CE S"i''
SERVICE ORDER NO.
N b
CITY, STATE, ZIP `: Al2 PE Fri'• A P� FK NQ; IAC? 92411
PICK UPDATE
Z
PHONE NO.'009 394— 74.:'4
Q
TYPED OR PRINTED FULL NAME & SIGNATURE
DATE
TRUCK, UNIT, I.D. NO.
9
NAME AZUSA LAND RECL41f1A?',.0N
EPA
NO CziD�ID?CII►7'6 6
DISPOSAL METHOD
ADDRESS a p 1 64, ('3ELOOSTLINE, X ❑ LAND FILL ❑ OTHER
CITY, STATE,ZIP''ZiUSh1 C91 91702
PHONE NO. (626)3,34 -0719 '
TYPED OR PRINTED FULL NAME 8 SIGNATURE
GEN
OLD/NEW
L A
TONS
TRANS
S B
C/O
RT/CD
HWDF NONE
DISCREPANCY
DATE
White & Yellow -TSD COPT. Pink - GENERATOR -COPY Blue -TRANSPORTER COPY I Goldenrod -TRANSPORTER COPY II
Yu�v,urc.nr am i vy-iuu wvrntu� ttiAr.Ih
State o a i ornio— nvironmenta rotection gency
Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of page 6. Department of Toxic Substances Control
Please print or type. Form designed For use on elite (12 -pitch) typewriter. Sacramento, California
UNIFORM HAZARDOUS
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99) Yellow: GENERATOR RETAINS
EPA 8700-22
1. Generator's US EPA ID No. Manifest Document No.
2. Page 1
Information in the shaded arerf
is not required by Federal low.
WASTE MANIFEST
91 81 11 41 010 51 I Q 1 3 1 2 17 12
1 °f 1
3. Generator's Name and Mailing Address
EAK SFR
A. State Manifest Document Number ^
Z 19 3 1
2021938.1-
P.00n. BO��sX.� 9 0 49-610 AVENILDA FERN
P.O.
111. State Generator's ID
A. Generafdh's;NTA, CA) 92253 IA QUINTA, CA
hone 1760 345-7755
5. Transporter 1 Company Name 6. US EPA ID Number
C. State Transporter's ID (Reserved.]
BRICKLEY ENVIRONMENTAL C 01 01 01 01 51 31 1 7 3
D. Transporter's Phone ( 909) 888-2010
7. Transporter 2 Company Name 8. US EPA ID Number
E. State Transporter's ID (Reseryed.]
ECTI 953 W. REECE ST.
F. Transporter's Phone (909) 884-7424
SAN BERNAIRDINO, CA 92411 ICIAIR101011011 0 419101614
9
AZ SA I.Ality. 1tECd�t•Address
CO. 10. US EPA ID Number
G. State Facility's ID
C1 Al DI 010191010171612161
1211 W. GLADSTOlE
H. Fatility�Pgn@
AZUSA, CA 91702 CAD 0 0 9 0 0 7 6 2 6
334-0719
113.
11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
12. Containers
Total
Quantity
14. Unit
Wt/Vol
I. Waste Number
No.
Type
° R Q ASBESTOS, 9, NA2212, PG III (NArRG #171)
state 151
5
B A
o, o
Y
EPA/Other
E
N
b.
State
E
R
EPA/Other
A
T
C.
State
O
R
EPA/Other
d.
State
EPA/Other
), Additional Descripyfbns for Materials Listed Above
K.,1jandling Codes for Wastes Listed Above
NON RCRk WVASTE Mr
03 b.
ASBESTOS CUtr°TAINING CONSTRUCTION MATERIALS
C.
d.
ls. s illJ�i�rnfl�grins aN�als�s���d�itiwnifAlrLformation
PRONE 300-530-3366 24 UR LNE GENC`C #1-800-535--5053
957 W. REECE STREET, SN 3JNO, CA 92411 _-_...
ASBESTOS RiiiIOVAL REQUIREMENT. 40CFY.61
(BAGGED, SEALED AND LABELED) EPA I ;:GIONI In -
16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified, packed,
marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
practicable•orid that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health
and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is
available to me and that I can afford.
Printed/Typed Name 1� - r
TM
l
Signature'
Month Day Year
R17.
Transporter 1 Acknowled ement of Receipt of Materials
p
Printed/Typed Name
Signoturp'i _
Month Day Year
0
18. Trans oder 2 Acknowled ement of Recei t of Materials
R
Printed/Typed Name
Signature
Month Day Year
It
19. Discrepancy Indication Space
F
A
C
I
L
1
20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
T
Printed/Typed Name
Signature
Month Day Year
Y
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99) Yellow: GENERATOR RETAINS
EPA 8700-22
r
I
`
If an x is checked, this application shall be considered rejected until
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
ASSESSOR'S PARCEL NUMBER
6S `e ` U f0
DEPARTMENT OF ENVIRONMENTAL HEALTH
days after date noted below may require repayment of fees.
Staff Spedallst Lot Inspection Required
PERMIT APPLICA710N FOR A SUBSURFACE SEWAIN DISPOSAL SYMM
APPLICANT. Submh this fomt with four copies of a SCALED phot plan (1.20 SCALE) drawn to County speelgeadons as indicated on the attached creek list.
Tho as Bros. Page Grid
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 appllca-
Date Lot Inspection Completed: 3 / ' o/ Inhlala
don shall remain valid for a period not to exceed one r ke ata ymam.
RemaA ,'p- w/ r4
LMS #
Q Soils Percolation Repon Required
Q Maintenance Booklet Provided
e Co coon, perscr
Adores a
CI State zip
Telephone
Own r
Address/
Q
lQ•I�
.jrp7✓�/
9
Talepn one
Q r
O .
LG
Na lAveltlrlg Unita
2 J04PPoperty Address
$oU Rate
Orea9e/Sand
t ing Tank ❑ am
Bedrooms, Fixture
Units
c1 Lot SW
Water AgancyNifsll
CvWD
Use of Permit P/P, SUP, PUP, BtG
S64rooM5
Legal Descrouon
riotF
AReep
NN
EAstinq Q
.5
�L'4 n1r.
ISac� G.J.
Dwelling, MH She Prep., etc.
Gal.
Le 199
Signature or t
Date
CHEPK 19 REQUIRED
If an x is checked, this application shall be considered rejected until
Q Detailed Contour Plot Plans Required (1 to 5 foot intervaO
the Information Is provided and the fee paid. Resubmihals later than 90
days after date noted below may require repayment of fees.
Staff Spedallst Lot Inspection Required
co Q Holding Tank Agreements Completed
0 VtCenlficadon of Existing S.D. System Required
Tho as Bros. Page Grid
U ❑ WOCB Clearance Required�+
Date Lot Inspection Completed: 3 / ' o/ Inhlala
(Attach for DOH -SAN -007, Santa Ana Region Only)
RemaA ,'p- w/ r4
Q Soils Percolation Repon Required
Q Maintenance Booklet Provided
Q Special Feasibility Boring Report Required
Q Flea! Inspection by Department of EMironmenffit Health is raq:::red.
❑ Rereview Required Inldals DDate
Please call 24 hours PRIOR to Inspection.
C142 / Sage Percolation Boling Report by.+�AiG �1Ms \�cProlect
M_ Z.1 0 Data 4-11-0
Sults Map Page 117, \Q.. Soil Type Approved Sy Data
No of Systems
T of Syetam(s)
Na lAveltlrlg Unita
(1) Septic Teruo
$oU Rate
Orea9e/Sand
t ing Tank ❑ am
Bedrooms, Fixture
Units
Grease InaZUrd Trap
I
AReep
NN
EAstinq Q
.5
ISac� G.J.
Z • r
Gal.
sq. R. Total Linear Sldewall Allowance
Bottom Area FL
4kQck1____sq. k running ft.
Inlet Tested Depth _Q NA
Proposed SCROM Tested Depth
Leach Sed sq. k. of
Area
Install_Une ft. long IN. wide with
min, inches mak tlrelnunes or
Leads linewbed epedal design for slope: (3) Plt Diameter Pb. Pita
Tol
Applicable Fm
NIA_Overburden Factor ❑ 9 r30 gee TD.
Maximum 011ier.
Allawable
Depth I _
Well Hevlaw Approved:Date: f Well Drilling Permit N
SIGNATURE ,p
Grading Plan Approved: Date: r�twrv� y L
Sewer verification Approved: '�i}i Date,. �.
Plan Check Only Approved: Date:
REMARKS: 58,A3 Zf%4kkkRj k J �i� U4di3fiOr�Sbi 1
Jt l..o-n1arvA VM4tr DL—
'I -IA
w
'1_IA - _L.LL'a t,
Thisepplicadon 3'APP 110MEaJOENIED for the category chocked In SECTION B
above, regarding the design of a subsurface disposal syodem as Indicated on the
ecomparlied plot plan, using the requirements sat forth In SECTION C above. A build-
ing permit is necessary for the installation of the above -designed system. No can.
atWohn Is peril alt d M tl,_ rap.lted reserved 100% expaoslaffAt
(1) Septic Tank must be 109 minimum from any wells.
(2) Leach Imes must be 10v minimum from any wells, including expansion area.
(3) Sewer linea must be s0' minimum 14
any walla.
(4) Seepage pits must be I! minjftru\"1'1\[,`L' any wells, Including expansion area
of
19 —00
to 13 �.
TT:TT TO, TO ZIHW
999
FOR OFFICES USE ONLY
9 " 9. Q
Revenue code^5 13� r e ja til s 00
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