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BPLB2014-1025I� �62014'116 (760)321-7450 Llc. No.::LIC-0001138 OF LA (UUup RTMENi ------------------------------------- VEL6i'M LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 1 hereby affirm under penalty of perjury one of the following declarations: VOICE (760) 777-7125 78-495 CALLE TAMPICO my License is in full force and effect. D License Class License No.: IC -000113 FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-.7153 Date: C C ntract Section 3700 of the Labor Code, for the performance of the work for which this permit'is BUILDING PERMIT issued. My workers' compensation insurance carrier and policy number are: OWNER -BUILDER DECLARATION Carrier: _ Policy Number: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State _ I certify that in the performance of the work for which this permit is issued, I License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any Date: 10/6/2014 Application Number: BPLB2014-1025 structure, prior to its issuance, also requires the applicant for the permit to file a signed Owner: statement that he or she is licensed pursuant to the provisions of the Contractor's State Property Address: 49778 ENTRADA CIR WIDENER BILL Date: j V V A plican . APN: 646240002 applicant to a civil penalty of not more than five hundred dollars ($500).: 49778 ENTRADA CIRCLE (_) I, as owner of the property, or my employees with wages as their sole Application Description: REPLACE SEEEPAGE PIT HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF LA QUINTA, CA 92253 COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, Property Zoning: INTEREST, AND ATTORNEY'S FEES. himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold Application Valuation: $9,000.00 IMPORTANT: Application is hereby made to the Building Official for a permit subject to or she did not build or improve for the purpose of sale.). the conditions and restrictions set forth on this application. Applicant: 1. Each person upon whose behalf this application is made, each person at whose construct the project. (Sec. 7044, Business and Professions Code: The Contractors' State Contractor: License Law does not apply to an owner of property who builds or improves thereon, and HAMMER PUMPING INC who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and HAMMER PUMPING INC employees for any act or omission related to the work being performed under or 0 OUTSIDE CITY LIMITS following issuance of this permit. � 0 OUTSIDE CITY LIMITS to LA QUINTA, CA 92253 Date: b 0 ner: n -�11 11 LA QUINTA, CA 92253 I certify that I have read this application and state that the above information is correct. I� �62014'116 (760)321-7450 Llc. No.::LIC-0001138 OF LA (UUup RTMENi ------------------------------------- VEL6i'M LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 1 hereby affirm under penalty of perjury one of the following declarations: (commencing with Section 7000) of Division 3 of the Bu ss an essions Code, and _ I have and will maintain a certificate of consent to self -insure for workers' my License is in full force and effect. compensation, as provided for by Section 3700 of the Labor Code, for the performance of License Class License No.: IC -000113 the work for which this permit is issued. _ I have and will maintain workers' compensation insurance, as required by Date: C C ntract Section 3700 of the Labor Code, for the performance of the work for which this permit'is - issued. My workers' compensation insurance carrier and policy number are: OWNER -BUILDER DECLARATION Carrier: _ Policy Number: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State _ I certify that in the performance of the work for which this permit is issued, I License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any shall not employ any person in any manner so as to become subject to the workers' city or county that requires a permit to construct, alter, improve, demolish, or repair any compensation laws of California, and a t, if I should ecome subject to the structure, prior to its issuance, also requires the applicant for the permit to file a signed workers' compensation provisions Section 3 00 of the b Code, I s II forthwith statement that he or she is licensed pursuant to the provisions of the Contractor's State comply with hos provisions. License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged Date: j V V A plican . 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).: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, (_) I, as owner of the property, or my employees with wages as their sole AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND•CIVIL FINES UP TO ONE compensation, will do the work, and the structure is not intended or offered for sale. HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, apply to an owner of property who builds or improves thereon, and who does the work INTEREST, AND ATTORNEY'S FEES. himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold APPLICANT ACKNOWLEDGEMENT withiri one year of completion, the owner -builder will have the burden of proving that he IMPORTANT: Application is hereby made to the Building Official for a permit subject to or she did not build or improve for the purpose of sale.). the conditions and restrictions set forth on this application. (_) I, as owner of the property, am exclusively contracting with licensed contractors to 1. Each person upon whose behalf this application is made, each person at whose construct the project. (Sec. 7044, Business and Professions Code: The Contractors' State request and for whose benefit work is performed under or pursuant to any permit issued License Law does not apply to an owner of property who builds or improves thereon, and as a result of this application , the owner, and the applicant, each agrees to, and shall who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and State License Law.). employees for any act or omission related to the work being performed under or (_) I am exempt under Sec. C. for is reas following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not to commenced within 180 days from date of issuance of such permit, or cessation of work Date: b 0 ner: for 180 days will subject permit to cancellation. CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is correct. I hereby affirm under penalty of perjury that there is a construction lending agency for I agree to comply with all city and county ordinances and state laws rel ing to building the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). construction, and hereby authorize representati sof this ci to ent up the bove- mentioned op rty for inspection purposes. Lender's Name: Date: iV Signature (Applic nt or Age Lender's Address: 4 /off �� DESCRIPTION FINANCIAL ACCOUNT CITY AMOUNT PAID PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for BUILDING STANDARDS ADMINISTRATION BSA $1.00 $0.00 DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE PERMIT ISSUANCE 101-0000-42404 0 $91.85 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for PERMIT ISSUANCE: $91.85 $0.00 DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE SEPTIC SYSTEM 101-0000-42401 0 $12.09 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE SEPTIC SYSTEM PC 101-0000-42600 0 $4.83 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for PLUMBING FEES: $16.92 $0.00 0• 00 '? Pel'i'Y11t ©eta1�5 PERMIUNUMBER City of La Quina BPLB20.4-1025 Description: REPLACE SEEEPAGE PIT Type: PLUMBING Subtype: Status: SUBMITTED Applied: 10/6/2014 PJU Approved: Parcel No: 646240002 Site Address: 49778 ENTRADA CIR LA QUINTA,CA 92253 Subdivision: TR 4293 Block: Lot: 17 Issued: Lot Scl Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $9,000.00 Occupancy Type: Construction.Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 °•int Sd?:T '�fS,i�+.. Details: ABANDON OLD SEEPAGE PIT AND INSTALL NEW 14' PIT. Process Summary Printed: Monday, October 06, 2014 8:48:46 AM 1 of 2 CVCTFMC CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID .. .. .. ... e , "'e CHECK # METHOD °•int Sd?:T '�fS,i�+.. BY • -NAME-TYPE ' ` ""' NAME _.. ADDRESS1 CITY $0.00 STATE ZIP PHONE FAX EMAIL APPLICANT HAMMER PUMPING INC 0 OUTSIDE CITY LIMITS LA QUINTA $0.00 CA 92253 ( Printed: Monday, October 06, 2014 8:48:46 AM 1 of 2 CVCTFMC CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY BY BSAS 561473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid for BUILDING STANDARDS ADMINISTRATION $1.00 $0.00 BSA: Printed: Monday, October 06, 2014 8:48:46 AM 1 of 2 CVCTFMC Perl'Y11t Det�al��5 PERMIT NUMBER City of M Quinta 25 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD BY PERMIT ISSUANCE 101-0000-42404 0 $91.85 $0.00 NOTES PLUMBING FINAL" Total Paid for PERMIT ISSUANCE: $91.85 $0.00 SEPTIC SYSTEM 101-0000-42401 0 $12.09 $0.00 SEPTIC SYSTEM PC 101-0000-42600 0 $4.83 $0.00 Total Paid for PLUMBING FEES: $16.92 $0.00 PARENT PROJECTS��W SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED RESULT REMARKS NOTES REVIEW TYPE REVIEWER DATE DATE NOTES PLUMBING FINAL" DATE PARENT PROJECTS��W BOND INFORMATION RETURNED STATUS REMARKS REVIEW TYPE REVIEWER SENT DATE DUE DATE NOTES DATE BOND INFORMATION ATTACHMENTS Printed: Monday, October 06, 2014 8:48:46 AM 2 of 2 COW"". Bin # City of LQ Quinta Building SL Safety Division P.O. Box 1504, 78-495 Calle Tampico . La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Address: r AoAr f Owner's Name: 1 l_ ( 0 —CQ E 9— A. P. Number: Z L(b 6072 Address: y U G/ Legal Description: City, ST, Zip: L Q- Q . t 064• Contractor: �4 M, M r_- ( PU t� ( Telephone: ' f :::<<: <<zr<%< •»<<< «> ::;.:>: <; Address: P 0 'Z> I -A Project.Description: City, ST, Zip: O_AV Z-0( L_ C L ---k Structural Calcs. Telephoner 01 ::/,.'iiii::: i:i%' !WIN= r� r-- State Lie. # : G(Q t 61•z) City Lic. #: 4' � l• Arch., Engr., Designer: Truss Calcs. Address: City, ST, Zip. Telephone: z% ;:<:.~<:?:.;:::;;::<;:;:::»>: »:<.::::<.:::::s :.•rs«:<:.s:<::;::><>:>r::s;:>:;>:-»:> < .S.. Construction Type: Occupancy: State Lic. # Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person �o ltd KtS&pj Lt Sq. Ft.: # Stories: -T# Units: Telephone # of Contact Person: ( Estimated Value of Projcet: t;5 APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES. Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance. Title 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2id Review, ready for eorrcctionsrssue Electrical Subcontactor List Called Contact Person Plumbing Grant Decd Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN IIOUSE:- '`d Review, ready for correctionsrissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees d'C i; y c 13 COUNTY OF RIVERSIDE • COMMUNITY HEALTH AGENCY 1EPARTMENT OF ENVIRONMENTAL HEALTH PLICATION TR/PM l.� Lot No. APN: ASSESSOR'S PARCEL NUMBER - - GHL v �/ f, v� ON# IN# n LMS#EHS 4 # a &o v SECTION A a . y: �. ;`+ =r' •m t AIG NT, CONTRA TOR ADDRESS CITY TELEPHONE # �� d ?6.B�1. 2. C 1 c a (o J7 IYI v OWNER ADDRESS ADCI TY T LEPHONE# Qp /� 419-1-19,iOTA JOB PROPERTY ADDRESS CITY Thomas Brothers © Map b 9a�''I_ADA ca, LA OJo�A CA. 'i"W LOT SIZE WATER AGENCY/WELL USE OF PERMIT Cvv�-0 i4DiJ(T(vA-A SECTIONS • FINANCIAL RESPONSIBILITY' NOTE: Pertaining to Deposit -Based fee Payments — Fees placed on deposit are intended to pay for System review including approval and installation. The project owner or applicant named in Section B will be subject to billing requests for additional monies should fees deposited to that point be insufficient. At final approval, the project owner or applicant named will receive a final statement and notice of any final fees due or refunds due (as applicable). ROP Fees: For Alternate Systems, renewable operating permit (ROP) fees will be due upon finalization of the project. ROP fees will be issued to the project owner or applicant named in Section B. SEND ALL BILLING MATTERS TO THE CLIENT OR ENTITY LISTED BELOW: CL NT / ENTITY NAM PSPONSIBLE B Am LU A IANC -C d IM IN MAILING ADDRESS t I CITY/STATE ZIP TELEPHONE # Poaax 2 49,%,,C6 -TRE Ria` cai 0-14 92235 3(A3603140 plicant ig ure: 1 Date: /O S . - For Office Use Onl CTION:C' " ;.._ . , ry,. # c �: •T. �, f '_. ,� i;. KBOX IF REQUIRED y box is checked, this application shall be considered rejected until the information is provided and the fees paid. Re -submittals later than 90 days rCHECBelow date noted below may require repayment of fees. olding Tank Agreements Required ❑ Floor Plan and/or Plumbing Layout Required ertificate of Existing OWTS Required ❑ Special Feasibility Boring Report Required QCB Clearance Required ❑ Detailed Contour Plot Plan Required (1 to 5 foot intervals) oils Percolation Report Required PRE SITE INSPECTION REMARKS INITIALS & DATES AOfeKLI (I�Prhs - (f l IT. _ Mf7,4tL )C(q T. /01? W C s5 .5' e-htif CIa( SECTIOWD Soils Percolation/Boring report by Project # Date Type of System: ❑ New Replacement ❑ Existing # Fixture units Septic tank Cap. Soil Rate ❑ Pump ❑ Addition ❑ ATU ❑ Connect to Sewer # Bdrms 1 GUU 1tr fv�i. f Sq. Ft. Bottom Area Total Linear Ft. Sidewall allowance ft Rock/ sq ft running foot. Tested Depth Maximum Trench Depth Install Lines ft long ft wide with min. inches rock below drain line, or Cl Plastic Chambers Leach Lines/bed special design for slope Applicable ❑ N/A ❑ Overburden Factor: Pit Diameter No. Pits Pit below Inlet (BI) Pit Total 7 pth Max Allowable Depth U Well Review Approved by: (Signature) CONSTRUCTION / INSTALLATION INITIALS & DATES -p 1 A GI ✓ �.SECTION'E3°;:� .- .;,ri,, s -""r ;�.«i.ar,, f=..r "�,;,•' !ty",h`t�4't'���: ti'1_Qi`'_ ;t�`��'°��'ti;x'ft��"�'� This Application is LL Approved ❑ Denied regarding the design of the OWTS as indicated on the accompanied plot plan using the requirements set forth in Section D aboverA building permit is necessary for the construction of the above designed system. No construction is permitted in the required reserved 100% Expansion area. (1) Septic tank must be 100' minimum from any wells. (2) Leach lines must be 100' minimum from any wells including expansion area. (3) Sewer lines must be 50' minimum from any wells. •(4) Seepage pits must be 150' minimum from any wells including expansion areas. EHS Sigure: Date: t� ' / t Environmental Resources Management Office Locations(/ t Environmental Health — ERM Division Environmental Health — ERM Division Riverside Permit Assistance Center Palm Desert Permit Assistance Center 4080 Lemon Street, 2nd Floor 38686 EI Cerrito Road Riverside, CA 92501 Palm Desert, CA 92211 RIVERSIDE 951 955-8980 PALM DESERT 760 393.3390 EH -SAN -122 Rev: 1109 Distribution: WHITE — Office File; YELLOW — Applicant; PINK — Bldg.,Rept.; GOLDENROD — Plans/Records COUNTY OF RIVERSIDE • COMMUNITY HEALTH AGENCY DEPARTMENT OF ENVIRONMENTAL HEALTH DEH -SAN -122 Rev: 1/09 Distribution: WHITE - Office File; YELLOW - Applicant; PINK - Bldg. Dept.; GOLDENROD - Plans/Records TR/PM Lot No. APN: ASSESSOR'S PARCEL NUMBER LAND USE APPLICATION 4), G 9 G - t-1 U - 0 U?.._ ON# IN# LMS# EHS # L[ (f SO SECTION .A ASGENT, CONTRA TOR ADDRESS CITY "Pin-&-u'440CA TELEPHONE # yA0l F" W6 ' L CiTlt t kol OWNER ADDRESS CITY T LEPH )NE # BILLOooetimp,. L19-1-19, CrJTaA0A .LAQQia° JOB PROPERTY ADDRESS CITY kA. Thomas Brothers © Map 6 k�4ADA C, P, LA QUf�rrA i.!) LOT SIZE WATER AGENCY/WELL USE OF PERMIT G' VV- 0 A 0b" i fun. (- SECTION t * FINANCIAL RESPONSIBILITY' NOTE: Pertaining to Deposit -Based fee Payments - Fees placed on deposit are intended to pay for System review including approval and installation. The project owner or applicant named in Section B will be subject to billing requests for additional monies should fees deposited to that point be insufficient. At final approval, the project owner or applicant named will receive a final statement and notice of any final fees due or refunds due (as applicable). ROP Fees: For Alternate Systems, renewable operating permit (ROP) fees will be due upon finalization of the project. ROP fees will be issued to the project owner or applicant named in Section B. SEND ALL BILLING MATTERS TO THE CLIENT OR ENTITY LISTED BELOW: RESPONSIBLE CLIENT/ ENTITY NAM ;4 r 4 MAILING ADDRESS t CITY/STATE ZIP TELEPHONE # Pa�d& 4g14 CAT4E�eQ�A �"r! �4 `22SS 360 ure: t Date: �ApplicantlSig /'0/-5 /1 IL/ Below — For Office Use Onl SECTION C _ CHECK BOX IF REQUIRED If any box is checked, this application shall be considered rejected until the information is provided and the fees paid. Re -submittals later than 90 days after date noted below may require repayment of fees. ❑ Holding Tank Agreements Required ❑ Floor Plan and/or Plumbing Layout Required ❑ Certificate of Existing OWTS Required ❑ Special Feasibility Boring Report Required ❑ WQCB Clearance Required ❑ Detailed Contour Plot Plan Required (1 to 5 foot intervals) ❑ Soils Percolation Report Required PRE SITE INSPECTION REMARKS INITIALS & DATES 0,(1rt kC r i�� l r� , :� Nf�l1 -i,• ,1ri'Lr �i, ��r?WTD "" SECTION D Soils Percolation/Boring report by Project # Date Type of System: ❑ New 136 Replacement ❑ Existing # Fixture units Septic tank Cap. Soil Rate ❑ Pump ❑ Addition ❑ ATU ❑ Connect to Sewer # Bdrms Sq. Ft. Bottom Area Total Linear Ft. Sidewall allowance ft Rock/ sq ft running foot. Tested Depth Maximum Trench Depth Install Lines ft long ft wide with min. inches rock below drain line, or ❑ Plastic Chambers Leach Lines/bedspecial design for slope Applicable ❑ N/A ❑ Overburden Factor: Pit Diameter No. Pits Pit below let (BI) Pit Total Depth Max Allowable Depth t Well Review Approved by: (Signature) CONSTRUCTION / INSTALLATION INITIALS & DATES i� t, eT A 6 SECTION E This Application isApproved ❑ Denied regarding the design of the OWTS as indicated on the accompanied plot plan using the requirements set forth in Section D above A building permit is necessary for the construction of the above designed system. No construction is permitted in the required reserved 100% Expansion area. (1) Septic tank must be 100' minimum from any wells. (2) Leach lines must be 100' minimum from any wells including expansion area. (3) Sewer lines must be 50' minimum from any wells. (4) Seepage pits must be 150' minimum from any wells including expansion areas. EHS Signafure:/ •,// Date:_A� / f � � 1 Environmental Resources Management Office Locations Environmental Health - ERM Division Environmental Health - ERM Division Riverside Permit Assistance Center Palm Desert Permit Assistance Center 4080 Lemon Street, 2n° Floor 38686 EI Cerrito Road Riverside, CA 92501 Palm Desert, CA 92211 RIVERSIDE 951 955-8980 PALM DESERT 760 393-3390 DEH -SAN -122 Rev: 1/09 Distribution: WHITE - Office File; YELLOW - Applicant; PINK - Bldg. Dept.; GOLDENROD - Plans/Records 1. ( 16a. I 6b. F 0 DEH-; County of Riverside Community Health Agency Department of Environmental Health 4080 Lemon Street, 2nd Floor P.O.. Box 1,206 Riverside, CA 92502 (951) 955-8980 ;ertification of Existing Subsurface. Sewage Disposal System. Date of Inspection L/7339 IC_^J f1" QA cZ. L/1�.RU1WTA CA 327-63 VN/�__ �LL :.� �0 F_tJ C -X._ (Property Address) (Owner's Name) (Legar Description and APN) FAILURE TO PROVIDE ALL REQUIRED INFORMATION SHALL PREVENT OWNER FROM OBTAINING ENVIRONMENTAL HEALTH SERVICES APPROVAL. >how design and location on a scale of 1" = 10' to 1" = 40' of the sewage disposal system and 100% expansion area n relation to attached dwellings, structures, wells, rocks, watercourses, etc. on required plot plan. i. I examined the. existing subsurface sewage disposal system at the above location on (date)�*a. date and determined that the septic tank capacity is UC�Cj gallons and that there is ofleachline bottom area. There are _bedrooms in the dwelling. There are 2.0 fixture units. >. There are leachline(s), each ft. long. There are plastic chamber(s), each ft. long. i. There are seepage pit(s), each in diameter, ft. deep. The leach bed Is ft. by ft., total sq. ft. 6f leachbed area. t. Construction of septic tank (please check one of the following): Aconcrete ❑ fiberglass ❑ steel ❑ other: >. Internal "dirbensions of septic (length $ ft., width , depth Condition of tank (please answer yes or no for each question): Yew No Inlet Tee present? 0 ❑ Outlet Tee present? ❑ Two compartments? ❑ Tank structure deteriorated?' ❑ If yes, briefly explain and indicate appropriate correction suggested: J. Condition of D -Box (if needed) Level ❑ Yes ❑ No replaced ❑ Yes ❑ No full of septic effluent ❑ Yes ❑ No i. While pumping the tank, did effluent flow back into tank from the absorption system? ❑ Yes [B, No �. Prior to pumping, was the liquid level in the tank above the outlet tee? ❑ Yes No Was the area around the lids oxidized? ❑ Yes NJ No i. Is design of system gravity feed? ' A Yes ❑ No Were well(s) observed on this or adjacent property? ❑ Yes ❑ No If yes, indicate distance of well from: Septic Tank ft. Leachlines ft. Seepage Pits ft. Distance from springs, lakes Septic Tank ft. and natural drainage courses: Leachlines ft. (circle appropriate item) Seepage Pits _ ft. f. Sewer is within 200 ft. of system and abuts property line. ❑ Yes �No ADDITIONAL COMMENTS: i. How long has dwelling been vacant? (if applicable) months weeks N/A'�t ] It is my opinion that the system appears to be in good working order and can be expected to function°.properly with proper maintenance. No repairs are necessary at this time. Kit is my opinion that the system is not in good working order and will not function properly without the following repairs: /,L1 SEEVAKN 21-rcaJ5� T c-yi`1 c ce fy udder pen of perjury that the foregoing is true and correct: AAS C0 L `AT r& G 6 PWA I Jgnature C-42 State License Number xpiratidn Dat SAD 4)WILCES d_14Mf pU M 0 10 C. . Print Nam Name of Pumper Company and Receipt umber/Name of Company Holdin C.42 License Address Phone Number rhe Dep`Art tnt of Enviro me tal Health has reviewed and approved this certification: Envu ntal Health Specialist Date flN 84 (Rev 6/04) Distribution: WHITE—Office; PINK—Contractor; YELLOW—Applicant _Dep6rtrlhent-OT-cnviiV illIEWE- 4080 Lemon Street, 2nd Floor P.O. Box 1206 Riverside, CA 92502 (951) 955-8980 1. Certification of Existing Subsurface Sewage Disposal System. Date of Inspection. ' X7339 1; t, rAADA cz. LAQuu- TA U Jn6-3 ���..�.. , ,0Iw�C-a" (Pr party Address) (Owner's Name) 6141n2.L1 n� 2." (Legs D scription and APN) FAILURE TO PROVIDE ALL REQUIRED INFORMATION SHALL PREVENT OWNER FROM OBTAINING ENVIRONMENTAL HEALTH SERVICES APPROVAL. 2. Show design and location on a scale of 1" = 10' to 1" = 40' of the sewage disposal system and 100% expansion area in relation to attached dwellings, structures, wells, rocks, watercourses, etc. on required plot plan. 1 a. I examined the existing subsurface sewage disposal system at the above location on (date) 1 date and determined that the septic tank capacity is --L066 gallons and that there is q. . of leachline bottom area. There are _bedrooms in the dwelling. There are 1^ O fixture units. b. There are leachline(s), each ft. long. c. There are plastic chamber(s), each ftlong. d. There are seepage pit(s), each in diameter, i L4 ft. deep. e. The leach bed is ft. by ft.,1 total sq. ft. 6f leachbed area. 4. a. Construction of septic tank (please check one of the following): VIconcrete ❑ fiberglass ❑ steel ❑ other: b. Internal dimensions. of septic (length Bft., width , depthft.) c. Condition of tank (please answer yes or no for each question): Yeses• O Inlet Tee present? [vr' Outlet Tee present? ❑ Two compartments? ❑ Tank structure deteriorated?* ❑ *If yes, briefly explain and indicate appropriate correction suggested: d. Condition of D -Box (if needed) Level ❑ Yes ❑ No replaced ❑ Yes ❑ No full of septic effluent ❑ Yes ❑ No 5. a. While pumping the tank, did effluent flow back into tank from the absorption system? ❑ Yes C&No b. Prior to pumping, was the liquid level in the tank above the outlet tee? ❑ Yes No c. Was the area around the lids oxidized? ❑ Yes No d. Is design of system gravity feed? '50 Yes ❑ No e. Were well(s) observed on this or adjacent property? ❑ Yes ❑ No If yes, indicate distance of well from: f. Distance from springs, lakes and natural drainage courses: (circle appropriate item) Septic Tank ft. Leachlines ft. Seepage Pits Septic Tank ft. Leachlines ft. Seepage Pits , ft. g. Sewer is within 200 ft. of system and abuts property line. ❑ Yes �No ADDITIONAL COMMENTS: h. How long has dwelling been vacant? (if applicable) months weeks WAX 6a. ❑ It is my opinion that the system appears to be in good working order and can be expected to function properly with proper maintenance. No repairs are necessary at this time. 6b. XIt is my -opinion that the system is not in good working order and will not function properly without the following repairs: ^� ) ' BIAS COI`( a f5 cfl, certify udder pend of perjury that the foregoing is true and correct. gnature C-42 State License Number 11xpiratidn Dat } iiaOWL C AIf'1fY1 P , Z.J . _Print Nami Name of Pumper Company and Receipt NumberfName of Company Holding C-42 License Address I ' Phone Number The Departint of EnvirrG�tal Health has reviewed and approved this certification: W L( Envirp tal Health Specialist Date S�/N- 4 (Rev 6/04) Distribution: WHITE—Office; PINK—Contractor; YELLOW—A THIS APPROVAL GRANTED BY THE DEPARTMENT OF ENVIRONMENTAL HEALTH .S.VALID FOR ONE, (1) YEAR FROM DATE OF APPROVAL. Food f o� Ganott Septic' �� s T ` c Trailer Park Sq: Ft. of Lead Line --Y-- Dwelling l�da.t .IyiaB1�.I `f o Commercial _...v Connection to Sever Swimming Pool Connect to Existing S. S. D. S. to on-site regenat cruting wer softening devices maybe discharged into the individual sewage dispo". farm herewith approved without ciraruuce from the Water Quality Control Board. .11 sewage disposal installation must conform with requirements of current Uniform Plumbing Code gay cutting, gradwr, o, filling in arca of leaching system may nullify scwagt disposal approvaL kpproval has been obtained from the Regional Water Quality Control Board for installation of the a cwage disposal system.