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10066 (SFD)1-1 ,. r! TAh • 44 P.O. BOX 1504 No. 10066 Building ._ 78-105 CALLE ESTADO Address "�"�`"� LA QUINTA, CALIFORNIA 92253 Ownar dj David Miller Mailing Address P. J. Box 722 City Zip LaQuinta 92253 564-5823 Contractor € acific trades Address sarae as above City lZip Tel.: —State Lic. City &Classif. B 425381 Lic.# 2955 Arch., Engr., Designer Address Tel. -City Zip 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 df the Business and Professions .Code, and my license is in full force and .effect.- t '\ .-. gal �.- `y `� , .---........r..J` 1 [ { m. r -,t SIGNATURE'----' L , 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, after, improve, demolish, or repair any structure, prior to its Issuance also requires the applicant for such permit to fife a signed' statement that he is licensed pursuant to the 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 of not more than five hundred do8ars.($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 of 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 safe. ff, 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 knprove 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 Contractors License Law.) ❑ I am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Work er's.Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No::• -.Company ❑ Copy is filed with the city. ❑ 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 (5100) valuation 'or less.) - I certify that in the performance of thg work for which this permit is issued, I shall not employ anyperson 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 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 BUILDING: TYPE CONST: OCC: GRP. A.P. Number Legal Description'Q/� / Project Description SSD i /co C 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: 4 Sq. Ft. Size 1240 No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Permit does not include block wall or pool Estimated Valuation Yt3 YV 74,344.00 /� A4e©0 PERMIT AMOUNT Plan.Chk: Dep. 250.00" ' .Plan Chk. Bal. 200,44 Const. 527.00 Mech. 49.00 Electrical 31b. 50 Plumbing 125.00 S.M.I. 7.60 Grading 20.00 Driveway Enc. 20.04 Infrastructure 1Q34.49 TOTAL 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: 4 CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL SO. FT. ® $ UNITS SLAB GRADE / i / / 2ND FL SO. FT. BONDING YARD SPKLR SYSTEM POR. SO. FT. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. S0. FT. GAS (ROUGH) DRAINAGE PIPING WAIL SO. FT. OTHER APPJEGUIP. DRINKING FOUNTAIN. SO FT ® TEMP. POLE URINAL ESTIMATED CONSTRUCTION VALUATION $ GROUT WATER PIPING NOTE Not to be used as property tax valuation FINAL INSP. FLOOR DRAIN MECHANICAL FEES WATER SYSTEM FINAL INSP. WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER ROOFING 1i/ GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED REMARKS: LAUNDRY TRAY 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 SO. FT. ® c WATER HEATER MAX HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1 V. c SEWAGE DISPOSAL SO.FT.GAR ® V4c HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PLCK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR GOND. SOLAR' SETBACK /Iq� GROUND PLUMBING // �3 NDERGROUND A.C. UNIT COLL. AREA SLAB GRADE / i / / ROUG PL B. BONDING HEATING (ROUGH) STORAGE TANK FORMS S C -TANK ROUGH WIRING. DUCTWORK ROCKSTORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEGUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. I FINAL INSP. 2 GRADING cu. yd. $ plus x$ =$ LUMBER GR. FRAMING L / ROOFING 1i/ • J �I1 ¢ V 3 A REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR FIREWALL 'n,n,c LATHING If YvI, 1Z �Q MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION / CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATOR=SIINITIALS GARDEN WALL FINAL Building f Address ) . Owner ! Mailing x Address _. City Zip Co-ntr96-ibr? P.O. BOX 1504 APPLICATION ONLY { 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 922 3 BUILDING: TYPE.CONST. OCC..GRP.. A.P. Number Tel. (otct� S��/_SflZ3 Legal Description .-C-4Z A � � S Project Description .._�.�.t..,.. Cit ' ZI Z Z�� TeIr Cicll State Lic. 5?S S City & Classif. Lic. # - Arch., Engr.,-- Designer.- Address Tel. t City Zip 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 effect. SIGNATURE - DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from theContractor'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 file a signed statement that he is licensed pursuant to the 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 of not more than five 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 of 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 o�f-F�roving that he did not build or improve for the purpose of sale.) - F'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,oLproperty,who builds or Improves thereon, and who contracts for - such projects with a contractors) nsed pursuant to the Contractor's License Law.) ❑ I am exempt under Sec. B. 81 P�.C.� his reason - - Date WORKERS' COMPENfATION DECLARATION I hereby affirm that I have a certificate 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 0 Copy is filed with the city. ❑ 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 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 Ihereby 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 BUILDING DIVISION Sq. Ft. Size New ❑ No. Stories Add ❑ Alter ❑ Estimated Valuation No. Dw. Units-.---• - Repair ❑ Demolition ❑ PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. ,Infrastructu -e G O TOTAL REMARKS 00502JO 4�jb 09-ii-9� ,� ,,,, SO I],V atmai"f�_ ills VV 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: V CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. ® $ UNITS SLAB GRADE ROUGH PLUMB. BONDING YARD SPKLR SYSTEM . 2ND FL. SO. FT. ® FORMS SEWER OR SEPTIC TANK ROUGH WIRING MOBILEHOME SVC. BAR SINK POR. SO. FT. ® GAS (ROUGH) METER LOOP GAR. SO. FT. ® POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CARP. SQ. FT. GROUT WATER HEATER WALL SQ. Ff. FINAL INSP. DRINKING FOUNTAIN SO 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.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM FIRE ZONE ROOFING KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SQ. FT. ® c BATH TUB LATHING SQ. FT. ®c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID @ 11/4 c SEWAGE DISPOSAL SQ.FT.GAR ® 3Ac HOUSE SEWER FINISH GRADING 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 INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL DESERT SANDS UNIFIED SCHOOL DISTRICT 82-879 Highway 111 NOTICE: Indio, CA 92201 Document Cannot Be Duplicated (619) 347-8631 Date 11/12/91 No. 10980 Owner Name Type of Permit David Miller No. 51365 street Velasco city La Quinta zip 92253 La Quinta Permit # 100W Log # Study Area 113 APN # # Lot # Square Footage 11240 Type of Development I Single Family Residence I No. of units Comments At the present time, the Desert Sands. Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It has been determined . the above-named owner is exempt from paying school fees at this time due to the following reason: This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 1.58 X .1 40 or $ 1,959.20 have been paid to D.S.U.S.D. for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By' David R. Miller Telephone 5G4-.ri,M'.,.,Nk Name on the check By James E. Lively Assistant Superintendent, Business Services Fee collected /exempted by Vickie J. Durrett Signature VUR Collector:, Attach a copy of county or city plan check application form to district copy for'all waivers. Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting Payment Received x Check r46;2480 Collector:, Attach a copy of county or city plan check application form to district copy for'all waivers. Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting For The Finest in Escrow Service . 44-900 SAN PABLO AVENUE TELECOPIER No. (619) 341-8296 PALM DESERT, CA 92260-3537 (619) 568-3627 David. Ross Miller 10/31/91 53430 Avemoda Carramza Escrow no: 10-16583 Quints, CA 92253 Property address: Vacant Land' APN 773-085-018 ,Q r� Lot 6 Block 64 %F •» a ^!�� ap^ � ",m TTj-actvSCAVLQ Unit 6:, - .. - �. rev* Y:.• _• .�e}^ T • '' - ' . _. ..1 � r,. Your•aboveA.numbered escrow has been closed in accordance with.,your instructions and. we enclose the `following: • r�/1.' Check fo `152.`30' t Closing statement/RESPA (PLEASE RETAIN FOR TAX PURPOSES) a� iY' Title- ,Insur nce Policy, 1922851 1se.uedt�by: First American TitlWXo oto follow IMPORTANT *.' Taxes are your responsibility :',The 2nd lialf 19.91-1992 Installment, is delinquent if not" paid, by •April •10;,, :1992 - ...'tn.09;`N'� ' t^!^ , �' tr�'T.. 5 �++•+n ,, s' •r- COUNTY TAXES ON REAL PROPERTY BECOME DELINQUENT.-•AS.FOLLOWS '.,FIRST""INSTALLMENT ON DECEMBER'10#-AND SECOND. INSTALLMENT ON APRIL�'10°: 'IF YOU `DO NOT RECEIVE A TAX BILL ONE MONTHrPRIOR'TO THE;DELINQUENCY DATE,,;`A WRITTEN REQUEST SHOULDtBE MADE TO THE COUNTY TAX§'COLLECTOR. YOU MAY, RECEIVE ,A'sSUPPLEMENTAL;�TAX BILJ. PRIOR : TO THE ABOVE DATES. RECORDED DOCUMENTS: r �c dna 7�kr f"\ 'aN�,C -Any t recorded document's.to wb CKi " directly by-the'-County'Recorder , o you We trust that this transaction has been handled to your satisfaction, and that we may again have the pleasure of serving•you in the future. Sincerely, Jackie Feldman Escrow Officer a COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No. 77� ENVIRONMENTAL SERVICES DIVISION — _ a uulj— 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. Approval of this application shall remain valid for a period not to exceed one year from date of approval. LOG +if VERIFY ITEMS IN SECTION A FROM A NON -FEE BUILDING & SAFETY (goldenrod) APPLICATION t, Contractor, Contact Person Phone Address City State Zip v. QX 72z Owner Phone Address City State Zip r Job Property Address City State Zip Legal Description Prop. (PM, Tract, Lot)Sa++`Q 4 b jk � 6 Lot Size Water Agency/Well Use of Permit PIP, CU, etc. Other to S� V U C ✓/ �� Dwelling, MH Site Prep, etc. �tJjZ-Z i9 I Signature of Applicant late 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 atter 4 7344 $ 55.00 (Attach DOH -SAN -53) 7352 $ 69.00 ❑ REREVIEW (2nd review same parcel) 7344 $ 55.00 ❑ HOLDING TANK 7351 $119.00 ❑ SITE EVALUATION In Conjuction with Critical Area 7346 $197.00 ❑ALTERNATIVE EXPERIMENTAL SYSTEM 7345 $656.00 C1 GRADING PLAN REVIEW DETAILED 1238 $104.00 ❑ SITE EVALUATION Lot Less than 10,000 Sq. Ft. 7347 $17200 ❑ GRADING PLAN REVIEW CURSORY .1238 $ 55.00 ❑ SECOND FIELD VISIT (SITE EVALUATION) 7346 $ 85.00 ❑ COPIES (LAND USE) 7786.81 $ .50 INITIAL DATE Holding Tank Agreements Completed ❑ Yes L/No ri5i lo-,2-0,1- U-,2-0j-Certification Certificationof Existing S.D. System Required ❑ Yes El"No I WQCB Clearance Required ❑ Yes II], No (Attach Form DOH SAN 007, Santa Ana Region Only) Soils Percolation Report Required ❑ Yes E(No Special Feasibility Boring Report Required ❑ Yes IINo Detailed Contour Plot Plans Required (1 to 5 ft. interval) ❑ Yes 0 No Grading Handout Provided ❑ Yes e(No Staff Specialist Lot Inspection Required ❑ Yes E(No Maintenance Booklet Provided ❑ Yes CZ No Lot Inspection Date Initials C/42 / Soils Percolation Boring Report by Lic/Project # Date Soils Map Page Soil Type C, [, Approved By $ Date /y -t No. of Systems Type of System(s) Holding No. Dwelling Units (1) Septic Tank Soil Rat9 5 Grease/sand ❑ Tank ❑ Replacement Bedrooms, F4xinre-Flnits Gr Intcp/LintTrap I %New ❑ AdditionfJ ❑ Existing �;, r% b^ f 1, r.• 1000 Gal. '� S �f Gal. Sq. Ft. Bott m Area T tai Linear Ft. Sidewall Allowance ft. rock/ sq. ft. per running ff. Install Lina(s) ft. long ft. wide with � Leach Bed sq. ft. of BottOm'•Ar\ Inlet Tested Depth O�KA min. inchesTck below drainlines or Proposed Bottom Tested Depth Leachlines/bad special design for slope: (3) Pit Diameter No. Pits Pit Below Seepage Pit Total Depth Olh r: Inlet (BI) (TD) --�. 07 3 r Applicable —/ ❑ 5 &16M / ax. Max. Allowable Depth N/A ✓ Overburden Factor 1 4� r Well Review Approved: Signature Date Well Drilling Permit # Grading Plan Approved: Signature Date REMARKS: :�a _ SY 1rr " j, w+ I� z �tl c>rD, / t cvL✓ C.., ..A20 c �J This applicatioKI'§'0PROVED)DANIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompanied pTot-plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the above -designed system. -1 Septic tank %mtist e ' minimum from any wells •r IU ' /o 1k - IA..A . IL (2) Leach lines must be 100' minimum from any wells, includin6 expansion area Seepage pits must be 150' minimum from any wells, including expansion area + /U ro,� Z. -u S + �wcT ► °- .- Signature of Health Off icia - Date /U `--2-J ❑ CASH ® CHECK NO. -21/_� 7 PECEIPT NO. j i (7 Issued By L�� Date /n — S DISTRICT: ❑ Riverside 1 Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe DOH -SAN -1 22 (Rev 6/91) DISTRIBUTION: WHITE—Office file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—Plans/Records 51;11= �gzfU REPORT OF INSPECTION — INDIVIDUAL SEWAGE -DISPOSAL SYSTEM PRIMARY TREATMENT consists of ❑Septic tank ❑Cesspool Septic Tank:*104rA/,Ot �j Distance from well, feet. Material, L D KL r �' /7 Number of compartments C Total liquid capacity, / m d C) gallons. Capacity inlet compartinent, gallons. Inside length, feet. Inside width, I feet. Liquid depth, feet. Cesspool: Distance om well, feet; foundation, feet; nearest lot line at ❑ front ❑ side O rear Inside diam er, feet. Depth, feet. Liquid capacity, gallons. Lining material SECONDARY TR TMENT• consists of O Tile disposal field ❑Seepage pits ❑ Other (Specify) feet. Tile Disposal Field: Distance from well, feet; foundation, feel; nearest lot line at ❑ front ❑ side ❑ rear feet. Total length of tile lines, feet. Number of lines, . Distance between lines, feet. Trench width, inches. Total effective absorption area in bottom of trenches, square feet. Length of each line, feet. Depth, top of the to finish grade, inches. Type of filter material: ❑ Grave O Broken stone ❑ Other (Specifij Depth of filter material beneath tile, inches. Depth of filter material over tile, inches. Seepage Pits: Number of pits, Outside diameter,— feet. DepthglN .1 feet. Lining material Distance from well feet; building foundation feet; nearest lot line at Ofront�side ❑rear feet. Inspection made by: ❑State ❑County O Local Health Authority �j, ' Inspected by al hp��� Date of inspection 19� �'irleJ , REPORT OF. INSPECTION — INDIVIDUAL WATER -SUPPLY SYSTEM Distance to nearest public water main, feet. Size of main, ' inches. Individual wells ❑ are O are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood ❑ are ❑ are not being developed with both individual water -supply and sewage -disposal systems. Lot size: feet wide, feet deep. Dwelling set back from front property line, feet. Individual water supply from: ❑ Drilled well ❑ Driven well O Dug well ❑ Bored well. Distance of well from: Building foundation, feet; nearest lot line at ❑ front ❑ side ❑ rear cast iron sewer, feet; tile sewer, feet; septic tank, feet; disposal field, seepage pit, feet; cesspool, feet; other sources of possible pollution,, Well construction: Diameter, inches. Total depth, feet. Type of casing, Depth of casing, Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute. Sealed watertight to depth of feet. Exterior space around casing sealed with: O Cement grout ❑ Puddled clay ❑ Ordinary backf ill. Well cover: ❑ Concrete . O Wood ❑ Metal. Openings in well cover watertight; ❑ Yes O No. Pump: O Shallow well O Deep well. Length of drop pipe, feet. Pump capacity, gallons per minute. Located in: O Basement ' O Pumproom off basement ❑ Pumphouse above ground ❑ Pump pit. Pumproom properly drained: O Yes • ❑ No. Pump mounting watertight: ❑ Yes O No. Type of storage: ❑Pressure ❑Gravity. Capacity, gallons. Has bacteriological examination of water been made? O Yes O No. If answer is "Yes," give date .19— Quality 19_Quality of water ❑ is O is not satisfactory for human consumption. Installation ❑ does O does not comply with approved exhibits, if any. Inspection made by: ❑State ❑County ❑ Local Health Authority. Date of inspection Inspected by , 19 r. US. OOVENNMENT PLAINT[NO orrICE: 1982-361-488/754, feet feet; feet. feet. G Form Approved VETERANS ADMINISTRATION/U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER -SUPPLY AND SEWAGE -DISPOSAL SYSTEM ' Y. {i VYYVOO HUDIFIIA on VA CASE NO. IIUDIFIIA On VA orFICE IMPORTANT—This (oral should be completed and (Wed as required by exlslhig law 38 U.S.C. 1804 and 1810.. PART 1—TO BE COMPLETED BY IIUU/FIIA OI1,VA PvIORTGAGEE NAME AND ADDRESS (Include ZIP Code) � • - ' MOTT I GAG011 Oil SPONSOn PIIOI•EIIIY ADINIESS r SUODIVISION/LOT NO. TOTAL NUMBEn IS 111F.IIE A BASE. MENT? C] YES ONO IS 11115 A NEW INSTALLATION? OYES ONO CAN 111E ATTIC On OTHER AREA BE MADE INTO AUDI TIONALBEDn00MS?(//"1'es,"howmany?) ❑YES ONO LIVING UNITS BEOnOOMS BA711S WATER -SUPPLY BY: ❑ PUBLIC SYSTEM ❑ COMMUNITY SYSTEM ❑ INDIVIDUAL SYSTEM DESIGNED FOR NO. OF BEDnOOMS IGAnBAGE DISPOSAL SEWAGE -DISPOSAL BY: ❑ PUBLIC SYSTEM ❑ COMMUNITY SYSTEM ❑ INDIVIDUAL ❑YES ❑ NO PAnT 11—TO BE COMPLETED BY HEALTII DEPAnTMENT On COMPLIANCE INSPECTOR INSPECTOR'S SKETCH (TO REP0R7`AS-8UIL7' DEVIATIONS FROM APPROVED PIAN/ i IT 7 — — — — — ------------ -- -- 4-- — — _t — — — — — — — — — — — — T_ — — — — — — — — — It is the ophdon of the ❑ Slate ❑ County ❑ Local Department of Ilenith ilial this Individual water -supply system ❑ is ❑ Is not satisfactory as a domestic water -supply for the subject properly. Itis the ophlion of the ❑ Slate ❑ County ❑ Local Department of IlenlIll that this individual sewnge•disposal system with proper malntenance ❑ Can be expected to function satisfactorily, and Is not likely to cleale unsanitary conditions ❑ Cannul be expected to function satlsfaclollly. DATE SIGNATURE TITLE NOTE: The health authority should complete the applopriate Opinion slalemenl above and affix dnle, siglnlure and title hI the spaces provided. NOTE: Use of the reverse of this form is al the option of the hcallh authorlly. PART I11—Fon USE OF FIELD OFFICE 1 have reviewed the foregoing and the perlincnt Compliance Insilcclion RepOl l and rcconllncnd Ihot IIIc Individual waler-supply SySlcnl be considered ❑acceptable ❑ not acceptable and that the sewage -disposal be considered ❑ icceptnble ❑ not nccepinbie DATE ' SIGNATURE TITLE ❑ IIUU AnCllll ECTUIIAL SECTION CIIIEF On DEPUTY CIIIEF ❑ VA CIIIEr APPIIAISAL SECTION On DESIGNEE - HUD ronM- 94573 - ` _ -14—b vn r V11M 7Y -Y:195, UCI 1976, WIIICII WILL NOT nE USED. 13 .•.J,- '. —S� col r3 6 (nL _ RIVERSIDE COUNTY DEPARTI DIVISION OF ENVIROI Food Establishment Trailer Park , Motel, Apt.,Hot¢1 _JL Dwelling 3b -400c" Commercial Eailding / Swinmir•, Pool 11 No on-site rerncrat:•ia. w -.11r n&kenlr..g d -vias f^,sy /system herewiih appro`' ,-d Water supply serving the i,. s::';1:.': `• f, :,,t .;� ;:.• All sewage .disposa; coo.-.cr) v!;; -!i . Any cutting gradi:-g, or ?Era in ex ,, -ss a! four (A Approval has been obtainsd from t:ie Regicnal WzL disposal system. ' / ' r ,�' i This is to certify that the Riverside County Department of nstallation the item(s) checked above. _ l ( seta ► O - - 9 1 By.� 9 � j ( P 1 I i i"'_T'�'"'. ^ fir-• i any r.1!�1'1»:: .,rON,too • ir'. .•.J,- '. —S� col r3 6 (nL _ RIVERSIDE COUNTY DEPARTI DIVISION OF ENVIROI Food Establishment Trailer Park , Motel, Apt.,Hot¢1 _JL Dwelling 3b -400c" Commercial Eailding / Swinmir•, Pool 11 No on-site rerncrat:•ia. w -.11r n&kenlr..g d -vias f^,sy /system herewiih appro`' ,-d Water supply serving the i,. s::';1:.': `• f, :,,t .;� ;:.• All sewage .disposa; coo.-.cr) v!;; -!i . Any cutting gradi:-g, or ?Era in ex ,, -ss a! four (A Approval has been obtainsd from t:ie Regicnal WzL disposal system. ' / ' r ,�' i This is to certify that the Riverside County Department of nstallation the item(s) checked above. _ l ( seta ► O - - 9 1 By.� 9 � j ( P 1 I i i"'_T'�'"'. ^ fir-• i any