09394 (PLBG). T ,
Building {
Address -,
77-955 SAL
Owner
maning
Address
City
Contractor
Address
Zip
Tel.
ty E lZip I Tel.
• Q-V"
P.O. BOX 1504 NO. WISU4
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253 Pr''
- BUILDING: TYPE CONST. OCC: GRP. -
)265 A.P. Number
Legal.Description
Project Description SEEPAGE PIT
---state LIC. f-Ity
& Classjf. 256184—A Lic. #194
ATch','Endr.,
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 of the jBusiness anndd Pr fessions Code, and my licenseisin full force and
effect , I is +.• C. f i 0 �7 -'g,td r
SIGNATt1RE/6'f. F C' h1 V�;I DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,eusiness 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 rile a signed statement that he Is licensed pursuant to
the provisions or 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 or Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty or not more than live hundred dollars ($500).
O 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 or completion, *the owner -builder will have the burden'
or proving that-he'did not build or Improve for the purpose of sale.)
❑ 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 Contractor's License Law.)
❑ 1 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
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,+l 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 or 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
ateMailing Address
City, State, Zip
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
BY:
PERMIT
Plan Chk. Dep.
AMOUNT.
:"" i 2�'
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
30.00
S.M.I.
Date Permit
Grading
Driveway Enc.
Validation:
Infrastructure
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:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
OTHER APPJEOUIP.
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
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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
IWATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
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 J.0
SEWER OR SEPTIC TAN
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
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 INSPECTIO — Gr!
c
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
,r,,.,r+�fy,w i�'"'rf'x'tt`'!+?t'%�{�"'��..�'9ryaFr'11�..1b•T"n1'xicti'}.:'T±,;ae.r+:a4".tw�-�rgy�r i?'�i'.>T`"�{Krt`..i ;/•}.��:�'W:.at`�l'v�4f i{7+.f'it,.�1''i'j�c'��-./'�'t.,'�"�-�"nr.Y i��F�'•��f,a+a�w�it..e:�...�'�y".
rte'• i , � �' '?t' j.
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Aft essors Pan* NM
ENVIRONMENTAL SERVICES DIVISION1773- lS.7.-,'� �i 4
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 IIsL
A non-refundable filing fee (see below) is required when the application is submitted. Check must be made payable to the Countyof.
z00 Riverside.1ApprovJ-
f this application shall remain valid for':a period not to exceed one year from date of approval.
VERIFY ITEM$1INISECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT 1 i! !IF /,d 011'�P
APPLICATION LOG #
t,Lt3ontractor, ContachPerson
Phone Address & Firm
♦ Owner
Phone 13 Mailing Address
Pu �, C o�
„�� - s L-/ '- w A 909
City
State
r
Zip
Job Property Address
/l., 7a o t�
Legal Descript' Prop. (PM, Tract, Lot)
Lot Sizetela
r A y/Watl
Use of Permit P/P, CU. etc. A 4VN,'41r4
Other
7 -
71''
add JOwshingpMam` e A,4 �) FX
,,.g
—
Data
Signature of Applicant
CATEGORY: REV CODE FEE —'
/SUBSURFACE
CATEGORY: REV CODE FEE
DISPOSAL 1238 $,15.-7�* I _ 1 �
❑ SITE EVALUATION UPON REQUEST 7349 $ 43.00
❑ MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $ 17.00
a. 1 at 4 Parcels (Each) 1238 $ 57.00
(Less than 1 year)
b. Each Parcel after 4 7344 $ 24.00
,❑ PRELIMINARY ELECTIVE 7352 $ 23.00
O Rereview (2nd review same parcel)' 7344 $ 24.00
EVALUATION (Attach DOH SAN 53)
❑ Site Evaluation in Conjunction with
❑ HOLDING TANK .7351 $ 47.00
Critical Area 7348 $111.00
❑ ALTERNATIVE/EXPERIMENTAL 7345 $222.00
❑ Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $ 87.00
INITIAL J? DATE
Holding Tank Agreements Completed ❑ Yes 'Ng -'r
.C,7
Certification of Existing S.D. System Required ❑ Yes 0No
WQCB Clearance required. (Attach Form ❑ Yes No
DOH SAN 007, Santa Ana Region Only)
Soils Ptercolation Report Required. ❑ Yes
Special Feasibility Boring Report Required. ❑ Yes No'
Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes o'0'
Other O Yes
Staff Specialist Lot Inspection Required ❑ Yes O" No
Lot Inspectihn Date
Soils boring report by Project ik 11i�� rt7 Ol Date 717%S� 71
//L))�
Soils Map Page Sca Type ARprwed by 0Y+ iRa.C. Dow 6 '♦7? 0 ' 7 '
No. of Syspme
E X I$T
Type of System(s)
0 ming Tank El Existing
Wo.3me11 Units
-Ba t wA Fixture Units;
(1) Septic Tank
�"JC/s1;,
Soil Rate
Graeae/Sand
teeae�nEcp
ArJ
r�9� lw; /��>Llslc
/�
..
,�ksao
Gal
y .,,
(2) Leech Line Sq. FL
Sidewall allowance
jT01WM4,';Q
Insall Line(s) fL long it wide
Leach Bed a% fL' '
N"'Bottorn trench
""'•-___^1
fl rode/ sq. fl
min- drainrmor
bottom
of �ltom area
per running ft
Leachlinse/bed special design for slope:
(3) Pit Diameter
l �r�
No. Pits
Pit Below
PitTotalTotal Depth
Seepage[
6 .
Applicable -
a
Inlet (BI)
(TD) '7
N/A Overburden factor
I- s
FfQ.u_
�I
- Max. Allowable Depth
No. 2 System IV 14 _- i Ddv, A4A-
N0 -?126DifGIVEN) /5v- ,;2I
REMARKS: �-
Gt . fi (✓ a �w9
76 ae4A!1'W
Tffis applicafioii PN V IED or catego. c iri SlECT10Ig B above, regad nf�g thrjsig�-�srlb�ut�y� d m e�mdt'ed�
on the accompanied plot p�using the require nts set forth_SE�IOI�.,Q„above...�...A .uildi&g..permit is necessary for the installation of
atx�ve designed system. const ron rs perm ed m the required rest3ved 1009b expansion area,
(1) Septic tank and sewer lines must be 50' minimum from any well
Leach lines must be 100' minimum from any wells, including expansion area
3) Seepage pits must be 1 minimum from any wells, in`c/l)u_ding e�c✓✓lpansionar�ea cJ}! / �"2.�G ^.y `
(/
Signature of Health Official_eta
RECEIPT NO. / Q/� <Issued By Date '��'FZ
DISTRICT: ❑ Riverside, o 141W ❑ Hemet ❑ Perris 7 Rancho Calif. ❑ Blythe "
DOH -SAN -122 (Rev. 3190) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
r
AffP1
L
Ll- pj IT
e e;?
HENDRICKSON -CONSTRUCTION; -'INC--
General Engineering Contractor • Underground Specialists.
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Post Office Box U • Cathedral City, CA 92234 • (619) 328-1747
License #256184-A'
s ray„
cGumW OF RIVERSIDE DEPPATFAM-N OF HEALTH
ENVIRONMENTAL HEALTH eMV'CES
_ F^od E .tal ilahm9nt Sewage Disposal
Gal.euPtir,Yank(� lvAc�
Tra!Ml W ct.. Sq. Rye! Leach Line
4�;'�`!, Act.., iistet �Up/;A3G ��epara Ptt(&e4LJ�'i rwuf
_ Dime a:C : : ! ' 5X/ST. 0FFIC� BLD6 � `T c'onn�L :an to Sewer �///���� �7v � p
Cci�:'riarc:zl {r.^ irii9� � TTA{ YL %
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