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9702-049 (SFD)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 Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty.,gf perjury that I am exempt from the Contractor's Lic nse Law for the following reason: I, as owner of the property, or my employees with wages as their sole ompensation, will do the work, and the structure is, not intended or offered for sale (Sec. 7044, Business & Professionals Code): ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). 4 c., (( ) I am exempt under Section B&P.C. for this reason , Date T Ct Gv -Signature of Owner 44 11 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one ofjhe 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 Sec ion 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. ATC ro 4D 141.9 _:� 57 - 9 (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 provisions of Section 3700 of. the Labor /Code, I shall forthwith comply with those provisions. I/ Date: ey , Applicant ..,6,,/� IX G 9 Warning: Failure to secure Workers' Comp sation coverage is unlawful and shall subject an employer to criminal ptaal , s 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 ' onhis application. fl 1. Each person upon whose behalf this application is made & each person of 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. /Si nature (Owner/Anent) <A-. Date 41- ` PERMIT # CONTROL # BUILDING PERMIT y,0.,��► 49 DATE lQ/17 VALUATION r�ggj r� LOT ! TRACT I, �, �i ,14 ^� ADDRESS 51-385 CALLE' J1�G�,.7.14'��f� JOB SITE APN 769-115-6,18 OWNER CONTRACTOR / DESIGNER / ENGINEER WAT,.t.."` S M -IC, S CDWtd:t'I� t:9'stlll.�l7Ft ' 03110 USE OF PERMIT AR) - PEWW f 13 , .s i4 ll IN LUN -3, 0k PiCK?f . BLYI' t-?. Elist fs WOOD FENCIi TRACT C01-437RUCTTON 1,496.00 SF PsaRt` UPAE`i:v 496.60 SSF 0i'UtMIU5 :Al2KfWT 4411,60 Sig (014X10419-000 1011 -OM -439-318 �ala+"�13�raic:AlI�c( IUI;.,j�:4i'I- ��3.;St1 3:I..IxC;rRAC'Al,FRH M1-00-420-000 �! • ��tA�y`�t,tfryl�xt) gnye�r,�r:+y' • • i'`.?}5i�t .t'VA�� F t'ON %T - .L�.' 310 '101 -000 -241 -IDM 4 �Ata`fivzdMIR $24.00 lt�ft #til`c Ytf1� "2't?i2t?. Ta[? 22540l;A43-342 -,Z{ -1,18 ` M:r;"lSFPLAN I0141 9+ ,WI -A45 6s ' 8U8,M'AI,CCN,;'I'3,2(,);Cf1(:9NAND PLAN C1 ECS, $3,575.83 LL PREPAID FEES PAID{^'� �i QQ�� j��yqq��•7y y �pq yatp (�a�� • ��(Y At, lJ�.�F4Rb7. IT.d VVI.114 ;011�J1�O �y 7 q p� $3�J.G.SY.AU APR 0 9 -1997 rREEA d %By DATE FINALED INSPECTOR • Ir INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. Framing Compressor Insulation 7 Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Prifif ' AL APPROVAL POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines 4 Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans OX 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 Vottage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final 7, - 1 - Utility Notice (Perm) COMMENTS: �� �l�i/� l/:�C%� G4� l /,y ���� 4W� /r 9702: �3 .f P.O. BOX 1504 'APPLICATION ONLY 7&105 CALLE ESTADO Addrress �✓� `CAIIE TAC ctnwBa LA QUINTA, CALIFORNIA 92253 Owner v IeJAdig 6, /1� s Mailing Address _? City I Zip Tel. .,>, Contractor 67 01,f1N,ga. �t.tl�ra Address ty State Lic. City & Classif. Lic. # Arch., Engr., Designer Address Tel. CityI Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION 1 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 1 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, 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). 161 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 of 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.) 1-1 1 am exempt under Sec. "Ir B. & P.C. for this reason Date 'Z!' 97 Owner _ /.lJl1 O7 S. dl!2Z WORKERS' OMPENSATION DECLARATION 1 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 youshould 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 DIVISION BUILDING: TYP�ECQNGGST. OCC. GRP. A.P.,Number / 7 (o `11 - AS- -018 Legal Description L6 7, Bim/ 3�, DE5 T C+ -A Z Project Description S/.c. Sq. Ft. No. No. Dw. Size 1 500 -3-J 2 Stories Units New 2-' Add ❑ Alter ❑ Repair ❑ Demolition ❑ A I n Estimated Valuation PERMIT AMOUNT Plan Chk. Dep. 2-15 0 • OCA Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Ceram 'n Side Setback from Property n FINAL DATE INSPECT 9 Issued by: Date Permit Validated by: CITYQ FLA Validation:r J CONSTRUCTION ESTIMATE NO, ELECTRICAL FEES NO. PLUMBING i EES 1ST FL. SO. FT. @ $ 2ND FL, S0. FT. @ POR. SO. FT. @ GAR. SO. FT. 0 CAR P. SO. FT. 0 WALL SO. FT, SO. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET +" YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation BONDING FLOOR DRAIN MECHANICAL FEES FORMS WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GAS (ROUGH) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APP./EQUIP. LAUNDRYTRAY AIR HANDLING UNIT CFM TEMP. POLE 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. is c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID @ 1V. c SEWAGE DISPOSAL SO.FT.GAR @ ?Ac HOUSE SEWER REMARKS: VENTILATION 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 INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL Desert Sands Unified School District Notice: 82-879 Highway 111 Indio, CA 92201 Document Cannot Be Duplicated 619-775-3500 CERTIFICATE OF COMPLIANCE Date 4/8/97 No. 15416 Owner Name Wally Miles No. 51385 Street Calle Jacumba APN # 769-115-018 Jurisdiction La Quinta Permit # Log # City La Quinta zip 92253 Study Area 115 Tract # Lot # Square Footage 1496 Type of Development Single Family Residence No. of Units 1 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: EXEMPTION NOT APPLICABLE This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 1.84 X 1,496 or $ 2,752.64the 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 Wells Fargo Bank/Crawford Investment Co. = z TelepE<one. ,619=320-4290 Name on the check t 7� By Dr. Carol McGrew j Administrator in Charge , Fee collected /exempted by Pauline Pearson Payment Received i $2;752.64 Check No. 742 Signature (It t t X1lu9 4` Q.�B I it A_ �/►'�- - r 40TICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to ;oiled them on the District('s)(s') behalf, whichever is earlier. Collector: Attach a copy of county or city plan check application form to district copy for all waivers. Embossed Original- Building Dept./Applicant Copy'= a Applicarit/Receipt ' Copy - Accounting TITLE TO SAID ESTATE OR INTEREST AT THE DATE HEREOF IS VESTED IN: JANICE WOMMACK, A MARRIED WOMAN AS HER SOLE AND SEPARATE PROPERTY THE ESTATE OR INTEREST IN THE LAND HEREINAFTER DESCRIBED. OR REFERRED TO COVERED BY THIS REPORT IS: IN FEE THE LAND REFERRED TO IN THIS REPORT IS SITUATED JN THE STATE OF CALIFORNIA, COUNTY OF RIVERSIDE, CITY OF LA QUINTA AND IS DESCRIBED AS FOLLOWS: LOT 7 IN BLOCK 3 OF THE DESERT CLUB TRACT UNIT NO. 2, AS SHOWN BY MAP ON FILE IN BOOK 20 PAGE 6 OF MAPS, RECORDS OF .RIVERSIDE COUNTY, CALIFORNIA. AT THE DATE HEREOF EXCEPTIONS TO COVERAGE IN ADDITION TO THE PRINTED EXCEPTIONS AND EXCLUSIONS CONTAINED IN SAID POLICY FORM WOULD BE AS FOLLOWS: 1. GENERAL AND SPECIAL COUNTY TAXES FOR THE FISCAL YEAR 1997-98, A LIEN NOT YET PAYABLE. 2. THE LIEN OF SUPPLEMENTAL TAXES, IF ANY, ASSESSED PURSUANT TO CHAPTER 3.5 COMMENCING WITH SECTION 75 OF THE CALIFORNIA REVENUE AND TAXATION CODE'. 3. AN EASEMENT FOR PUBLIC -UTILITIES A RLOCATED WITHINIDHETAL WESTERLY 5SFEET SHOWN ON THE MAP OF SAID OF SAID LAND. 4. AN EASEMENT FOR POLE LINES, CONDUITS AND INCIDENTAL PURPOSES, IN FAVOR OF CALIFORNIA ELECTRIC POWER COMPANY, IN. INSTRUMENT RECORDED DECEMBER 19, 1941 IN BOOK 527 PAGE 22 OF OFFICIAL RECORDS .OF RIVERSIDE COUNTY, CALIFORNIA. SAID EASEMENT IS DESCRIBED AS BEING OVER, ALONG, ACROSS OR BENEATH ALL STREETS, ALLEYS, HIGHWAYS, PUBLIC PLACES, AND WITHIN 5 FEET OF ALL DIVISION PROPERTY LINES (EXCEPT SUCH LINES AS COINCIDE WITH BOUNDARY LINES OF STREETS'AND ALLEYS), AS SHOWN ON THE MAP OF SAID TRACT. Page 2 ppppp-- ��- acific Coast Escrow Corporation 74-920 HIGHWAY 111 * INDIAN WELLS, CALIFORNIA 92210 TELEPHONE (619) 568-0344 Address: LOT 7, vacant land APN#769-115-018 Unit: #2 • Tract: DES CLUB ESCROW INSTRUCTIONS Phase AMENDED Escrow N0.1 6654 Indian Wells Calif., March 10, 1997 TO: PACIFIC COAST ESCROW CORPORATION The above numbered escrow shall hereby be amended as follows: Title shall. be vested as: WALLACE S. MILES, An unmarried man as his sole and separate property. All other terms and -conditions shall remain the same. BUYER(S): YER(S): i Wallace S. Miles SIGN AND RETURN SELLER(S)_ Janice Wommack Each of the above signed states he has read the foregoing instructions and understands and agrees to them. ; Order No. 2070681 t' \ Escrow: No. 16654 Loan No. WHEN RECORDED MAIL TO: WALLACE S. MILES APRIL 4, 1997 INSTRUMENT NO. 115067 4IL TAX STATEMENTS TO: SPACE ABOVE THIS UNE FOR RECORDER'S USE DOCUMENTARY TRANSFER TAX $......9...79 ..... SAME AS ABOVE A Computed on the consideration or value of property conveyed; OR .....Computed on the consideration or value less liens or encumbrances remaining at time of sale Signature of Declarant or Agent determining tax -Firm Name APN: 769-.115.-018 . TRA: 02001.. GRANT DEED FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, JANICE WOMMACK, A MARRIED WOMAN AS HER SOLE AND SEPARATE PROPERTY hereby GRANT(S) to WALLACE S. MILES >-1 SINGLE MAN the real property in the City of La Quinta County of Riverside State of California, described as .LOT 7 IN.BLOCK 3 OF DESERT CLUB TRACT UNIT NO. 21 AS SHOWN BY MAP ON FILE IN BOOK 20 PAGE 6 OF MAPS, RECORDS OF RIVERSIDE COUNTY, CALIFORNIA February 13, 19.97 Dated >Nt►ssour i } STATE OF-@Ati/F�6R� L ) ss. COUNTY OF l L OIC f im m } On aI 7. 1992 before me, personally appeared O�vwCJl 1JJ4'►M�Wt Janice.Wommack personally known to me (or proved to me on the. basis of satisfactory evidence) to be the persons) whose name(s) islaresubscribed to the within instrument and acknowledged to me that WsheM'Ay executed the same in .bWherAheir authorized capacity(les). and that by*AffierAhOW signatures) on the Instrument the person(s) orthe entity upon behalf of which theperson PATRICIA A RICHARDSON acted, executed the Instrument. NOTARY PUBLICSTATEOFMISSOURI WITNESeS wand and official CHRISTIAN COUNTY \`i�") lnJ,l—nMMISSION EXP. )UNE 11,2000 Signatur _tel f1,� (This area for official notarial seal) MAIL TAX STATEMENTS AS DIRECTED ABOVE 1002(1/94) P ASSESSOR'S PARCEL NUMBER COUNTY OF RIVE76 % _ ��S _O4RSIDE HEALTH SERVICES AGENCY d 0 DEPARTMENT O ENVIRONMENTAL HEALTH RMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM PLICANT: Submit this form with four copies of a SCALED plot plan (1-20 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. A proval of this appliga ' 1J3-26--97 16: 60001 -tion shall remain valid for a period not to exceed one year from date of payment. 2280 ' n 1238 $214.0( LOG `# C /T 0 A Q Aa4 ^- CHK $214,. OM Agent, Contractor, Contact Person GAl Address ity State Zip , _ Owner �(A L ACE Address City State Zip Telephone Q Z 0 Job Property Address Sl - 3 8S A c L IF JA Nm 9, City 6q Qcf/ 1✓r�r Zip 9oZv��3 U Lot Size l Qater AgencyI /o.�/c�+F«q� vAc �Es� Use of Permit, P/P, SUP, PUP, etc. w w . G,4-��c6, Legal Description �O / n/ acK.3 G�f�; C�ueTi0- ��� #� 15,10)(100 l 1/l L ellin 9, MH S to Prep., etc. ' Signature of Appl' nt Date CHECK BOX IF REQUIRED ❑ Holding Tank Agreements Completed . ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) ❑ Certification of Existing S.D. System Required ❑ Grading Handout Provided m ❑ WQCB Clearance Required ❑ Staff Specialist Lot Inspection Required Z O (Attach For DOH -SAN -007, Santa Ana Region Only - ❑ Lot Inspection f- LISoils Percolation Report Required LU ❑ Date Lot Inspection Completed: Initials (A ❑ Special Feasibility Boring Report Required Remarks:. ❑ Maintenance Booklet Provided Initials Date Q Final Inspection by Department of Environmental Health is required. C/42 / Soils Percolation BoringReport by Ur/Project # Date '% I ' / S Soils Map Page Soil Type .1. Approved By Date No of Systems Type of System(s) Tank O Replacement No. Dwelling Units(d (1) Septic Tank Soil Rate GNaktSand O is Grease'litt Unt Trap f New Addition WNew ng 3B�i�•t; TT' �, 00U G� �, 3 — �. S G� Sq. Ft. om Area Total Unear Slde all Allowance ft. rock/ sq. ft. running ft. Install Une(s) ft. long ft. wide with Leach Bed sq. ft. of Bot, m Area Inlet Tested Depth NA min. ches rock below drainlines or Proposed Bottom Test. pih Z Leach Ines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Otho O / Total Depth Allowable P Applicable ( Depth / W N/A Overburden Fa or TD� r N Well Review Approved: Date: Well Drilling Permit # SIGNATURE Grading Plan Approved: Date: SIGNATURE Sewer Verificatio Approved: Date: REMARKS: C oe—Y 44 This application Is P� ENIED+for4he-categoV—Zh cked in SECTION. B FOR OFFICE USE ONLY -abGve-regarding the design of a subsurface disposal system as Indicated on the acompanied plot plan, using the requirements set forth in SECTION C above. A build-0 Ing permit is necessary for the Installation of the above -designed system. No construe- Revenue code d Fee $ tion is permitted In the required reserved 100% expansion area. Septic Tank must be 1W minimum from any wells.�i/0�+'` t^� Check # �Q �3(1) ( —4Z6 (2) Leach lines must be 100' minimum from any wells, including expansion area. Date Initial .Q ✓�E/PT /10' �t�g (3) Sewer lines must be 50' minimum from any wells. Z O () Seepage pits must be 150' minimum from any wells, Including expansion area. w '^ VJ V llrr Signature of Health Official 7% Date ISH -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records