Riv Co Permit Application for Sewage Disposal SystemG
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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 scaler) 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,
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ti aa�� Building Department Application Log #
Name (Owner. Agent. Contractor„ Etc.) U
Mailing Address f %�
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Zip Code Telephone
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-Job Property Address
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0011
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Legal Oescppuon of Property (Lot. PM. TR)
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'Assessor's Parcel No,
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Use of Permit 1J ,fhCXJ ,)lay ma"A Cesst
Lot Size
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SfD. MH Sde:Preparation Etc,
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Signature of Applicant 91/ Date -`
•The:above information must be verllled from Building Apptkdtyorf
STAFF USE — DO NOT WRITE BELOW THIS UNE
Initial Date
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Certification Existing S.D. System El Yes
of. required:
WQCB Clearance ❑ Yes
required. 1
Soils feasibility report required. El Yes �i6e
Special feasibility boring.report required. ❑ Yes e
Detailed contour plot plans required. 11 Yes o
Staff Specialist approval required. ❑ Yes No Lot Inspection Date
Soils/boring report by Project # Date
Soils Map Page -1147d Soil'Type• Approved by Date
Type of System: �
No. of Bedrooms
(1) Septic �nnk
Sail Soil Rate Required
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LHrN
❑ Existing ew ❑Additional ❑Replacement
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(2)' ach line sq. ft.
Sidewall allowance
'Ft.
Install Lines) Ft. Long,
Ft. inches
L h bed Sq.
Ft.
(Bo trench area)
ft. rock/ Sq.
wi e min.
ofbo�
per running ft. TeIA
rock below drain lines
area
Leach lines/bed-special design for slope:
(3) Pit Diameter
No, Pits
Pit BI
Seepage Pit total depth
Applicable
NLA_ t��factorf'
Overburden
Max. allowable depth
77
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This application is roved for the design of a subsurface disposal system as indicated on the accompanied plot plan using the requirements.
set forth in Section B a vs. A building permit is necessary for the installation of the above -designed system.
(1 Septic tank and sewer lines must e,40'' from any wells^!
(2) Leach lines must be 100' min. from any wells including ex si area s X71
Seep e?ts must be 150' min. ,from any wells includin expansion area,,!
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Signature of Healih Official i
RECEIPT NO. 3316
District: ❑ Riverside .0Indio ❑ Hemet
Distribution: WHITE—Office file YELLOW—App
DOH SAN 122 (Rev 8187)
Issued by -� Z_ f Date-
0
ate
❑ Perris ❑ Rancho Calif. ❑ Blythe
int PINK—Bldg. Dept. GOLDENROD—Pending File