Loading...
No Permit No (PLBG)k COUNTY OF'RIVERSIDE HEALTH SERVICES AGENCY ASSESSOR'S PARCEL NUMBER 19 DEPARTMENT OF ENVIRONMENTAL HEALTH 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 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. Approval of this applica- tion shall remain valid for a/period not to exceed one year from date of payment. LMS # Age.5t, Co tractor, Cont�rson Y l G /`�✓ Address I City tate Z -gyp l gU UQrI / �. ✓� Z k irf Telephone 5� -1--6 / Q me vt'a t he z Address City Sta a Ip &$o Av-e f Ido T 1 rIZZ5_ Telephone f�,G ZO Job operty A dress • sa- 6�0 1hllFIVI DA S(AA tF city L 4 611, M Zi y 0 U LU Lot Size /ater /00 Agen 811�'j f j CVow((A 4c�Ey Use of Permit, P/P, SUP, PUP, etc. ,�EatoDE�I�Ooino� ExifT Legal Description L01- /S�� Ycoue, /G( ellin FJ-5ite+mp--etc. Q.7 / 14 &WIAI A N� Signature of Appli ni t EX1nr1 X Date nO� CHECK B9 IF REQUIRED I t If any box checked, this application shall be-eo)dered rejeofed until ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) the information is provided and the fee paid. Resubmittals•later than 90 days after date noted below may require repayment of fees. ❑ Staff• Specialist Lot Inspection Required co ❑ Holding Tank Agreements Completed Z Thomas Bros. Page Grid 0 0 LICertfication of Existing S.D. System Required U ❑ WQCB Clearance Required ❑ Date Lot Inspection Completed:, Initials + N (Attach for DOH -SAN -007, Santa Ana Region Only) Remarks: ❑ Soils Percolation Report Required ❑ Maintenance Booklet Provided ❑ Special Feasibility Boring Report Required Rereview Re Required ' Initials Date ❑ q ❑Final Inspection by Department of Environmental Health is required. Please call 24 hours PRIOR to inspection. C/42 / Sails.Eez.Qlsjti9m.BeFin9 y Report b 5W/ %41111 L vzp f�� r'C/RreeGt+# 6 /.r Date 9 4 Soils Map Page Soil Type Approved By Date No of Systems y/ fr/A/L Type of System(q) � Holding Tank ❑ Replacement ❑ Ne U ddition No. Dwelling Units / Q'/IX (1) Se tic Tank Bedroom , Mxtuce•draits W_ k1r7 9/,1v. 2 dW7/) Soil Rate Grease/Sand Grease Intcp/Lint Trap C�) fisting �T � ,� A j'X , � Q 066GaI Gal. Sq. Ft. Bb om Area Total Linear Sidewall Allowancei. �^ jJ ft.�sq. ft. running ft. � Install Lines) ft. long ft. wide with Leach Bed sq. ft. of ottom Area Inlet Tested Depth ❑ NA Proposed Bottom Tested Depth1`� min. �' inches rock be o d alnlines or U Z Leach lines/bed special design for slope: Applicable- (3) Pit Diamet9r EX�l r No Pits ��;/fr. ol Pit Below Inlet (BI) E i 1 Seepage Pit TaID epth Maximum Allowable Depth Other: LUN/A Overburden Fac � l C l TD Well Review Approved: Well Drilling Permit # SIGNATURE Grading Plan Approved: / /� Date: ' 7jf1_ Q ue, �, �'�`„�' ,D� /! I S e Verification Approved: 6A .le ��Il�_ r Date: ` 3-04 / �"�' / Plan Check Only Approvveed:/— 10 -Date: � REMARKS: aGtOW 3 Q� 14 This application APPROVED above"r 6NfEDsfor tis go ch`dckeYJ'Pt1^3ECTION"B- t e disposal OFFICE 0� : %PO(0 �E Me/ ! garding esign o a subsurface system as indicated on the acompanied the 7QR plot plan, using requirements set forth in SECTION C above. A build- ing permit is necessary for the installation of the above -designed system. -N-c clh- Revenue code-5�3r.(7� 4��� Fee $ /% O e . e Alb rE: � r .4- V4 (E _ Cor- 4.� /W/ � CAI# (1) Septic Tank must be 100' minimum from any wells. Check # (2) Leach lines must be =100' minimum from any wells, including expansion area. Date 1017 Initial 0 + (3) Sewer lines must be 50' minimum from any wells. / �.L j 4 / Z LD (4) Seepage pits must be 150' minimum from any wells, including expansion area. �....+....._ I— U l LU U) Signature of Health Official / 1--.3-DG Date r WCn-0A"-rcc fine. vivo! urauruuwn: vvnr r e—Unice rue;YELLOW—App scam; PINK—ulog. Dept.; GOLDENROL—Plans/Records STATE OF CALIFORNIA t�'bwl.tstollotion DEPARTMENT OF VETERANS AFFAIRS Existing Installation DIVISION OF FARM AND HOME PURCHASES O ?� 200 REPORT OF INSPECTION INDIVIDUAL SEWAGE -DISPOSAL AND WATER SUPPLY SYSTEM (To be headed in by District Office) Property e //__ p /� �� ,,l Address - �� ' 1D�� (�v ., ii %. City .�f� —County f1/C4S(tj Applicant Contractor or Builder_ _ SUBDIVISION NAME` -- - TOTAL NUMRER: BASEMENT UVntG UN11S et oroaMs RAMS ties L) No BLOCK NO. LOT NO. Can attic or other area be made Into additional bedrooms? lJ Yes 11 No WATER SUPPLY BY: 1'uhlic ststcm -- ComnLill ity systenT EI-111dividual SEWAGE DISPOSAL BY: -- F, Public system El Community systern Individual PART 11.—TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH (If Yet, how many{) SYSTEM DESIGNED FOR NO. Of BDRMS.F GARBAGE DISPOSAL 11 Yes 1:1 No If11 �11l�I III� I�l1 Iii Jill riB Ila! ENdENNE 1 AiO�BpIiNI W n _ai�f 36 11�� olilliili smile II�a119i �I�i101 Y�I l� Ra 'It is the opinion of clic F] State n County n Local Departhicnt of health that this individual water -supply system is is not satisfactory as a domestic water supply for the subject property. It is the opinion of the , tae :ounty n Local DepJartinent of health that this "in'�dividua,lIl``sewage-disposal syys'-�" tem with proper mai tet ince. S L S�S {ehil tv S�l�� A 1 4C" k) R n ��yttYnLVlpl��7 Can be expectediko ' nc Ion sausly, end F] Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATESIG AT E TITLE la ��D�9i Sim 'U, h7e NOTE: The heal authority should complete file appropriate opinion statement above and affix date, signature and title In the spaces provided. %%% Use of the above grid for Health Department Inspector's sketch as well as use of the back of this form Is at the option of the health authority. PART III. - FOR USE OF DFH OFFICE TO THE DISTRICT MANAGER I have reviewed the foregoing and the pertinent DFI-I Compliance Inspection Report, and recommend that the individual sewage—disposal syste and water supply system be considered U acceptable U not acceptable. Remarks: Dale , 19 _ Signed Title DFH 2218 — Individual Sewage—Disposal and Water Supply System Report of Inspecti (COMPARABLE TO F11A FORM 2218 - nEv. 1/54) , REPORT OF INSPECTION -INDIVIDUAL SEWAGE -DISPOSAL SYSTEM Inspection made by: ❑ State. ❑ County. ❑ Local Health Authority. �%�j° Inspected by v' Date of inspection /e� 3D 19� E-) (nrc *6 !Sf REPORT OF INSPECTION --INDIVIDUAL WATER -SUPPLY SYSTEM Distance to nearest public water main,_. feet. Size of main, inches. Individual wells ❑ are ❑ 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 ❑arc ❑ 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. ❑ Dug well. ❑ Bored well. Distance of well from: Building foundation, ' feet; nearest lot line at ❑ front, ❑ side, ❑ rear, feet, cast iron sewer, feet; the sewer, feet; septic tank, feet; disposal field, feet; seepage pit, feet; cesspool, feet; other sources of possible pollution, feet. Well constructions Diameter, --i nches. Total depth, feet. . Type of casing, _ Depth of casing, feet. Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute. Scaled watertight to depth of feet. Exterior space around casing sealed with: ❑ Cement grout. ❑ Puddled clay. ❑ Ordinary backfill. Well cover: ❑ Concrete. ❑ Wood. ❑ Metal. Openings in well cover watertight: ❑ Yes. ❑ No. Pump: ❑ Shallow well. ❑ Deep well. Length of drop pipe, feet. Pump capacity, gallons per minute. Located in: ❑ Basement.. ❑ Pumproom off basement. ❑ Pumphouse above ground. ❑ Pump pit. Pumproom properly drained: ❑ Yes. ❑ No. Pump mounting watertight: ❑ Yes. ❑ No. Type of storage: ❑ Pressure. ❑ Gravity. Capacity, gallons. Has bacteriological examination of water been made? E)Yes. ❑ No. If answer is "yes," give date 19_ Quality of water ❑ is ❑ is not satisfactory for human consumption. Installation ❑ does ❑ does not comply with approved exhibits, if any. Inspection made by: ❑ State. ❑ County. ❑ Local health Authority. Inspected by Date of inspection , 19_ ( rITIAE PRIMARY TREATMENT consists of Septic tank. ❑ Cesspool. Septic Tanks Distance from well, feet. Material, Number of compartments Total liquid capacity, _%M gallons. Capacity inlet compartment, gallons. �tp Inside length, g feet. Inside width. _L2_feet. Liquid depth,41 -feet. Cesspool: Distance from: Well, feet; foundation, feet; nearest lot line at ❑ (tont, ❑ side, ❑ tear, feet. Inside diameter, feet. Depth, feet.. Liquid capacity, gallons. Lining material SECONDARY TREATMENT consists of [-j'file disposal field. Seepage pits. Other Tile Disposal Field: Distance from: Well, feet; foundation, feet; nearest lot line at ❑ front, ❑ side. ❑ tear, feet. Total length of tile lines, feet. Number of lines, . Distance between lines, feet. Trench width, inches. ' Total effective absorption arca in bottom of trenches, square feet. Length of each line, feet. Depth, top of tile to finish grade, inches. Tyle of filter material: ❑ Gravel. ❑ Broken stone. Other Depth of filter material beneath tile,; inches. Depth of filter material over tile, inches. Seepage Pits: �. %/ Number of pits Outside diameter, feet. Depth, feet. Lining material Distance from: Wcll, feet; building foundation, feet; nearest lot line at ❑ front, ❑ side, ❑ rear, feet. Inspection made by: ❑ State. ❑ County. ❑ Local Health Authority. �%�j° Inspected by v' Date of inspection /e� 3D 19� E-) (nrc *6 !Sf REPORT OF INSPECTION --INDIVIDUAL WATER -SUPPLY SYSTEM Distance to nearest public water main,_. feet. Size of main, inches. Individual wells ❑ are ❑ 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 ❑arc ❑ 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. ❑ Dug well. ❑ Bored well. Distance of well from: Building foundation, ' feet; nearest lot line at ❑ front, ❑ side, ❑ rear, feet, cast iron sewer, feet; the sewer, feet; septic tank, feet; disposal field, feet; seepage pit, feet; cesspool, feet; other sources of possible pollution, feet. Well constructions Diameter, --i nches. Total depth, feet. . Type of casing, _ Depth of casing, feet. Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute. Scaled watertight to depth of feet. Exterior space around casing sealed with: ❑ Cement grout. ❑ Puddled clay. ❑ Ordinary backfill. Well cover: ❑ Concrete. ❑ Wood. ❑ Metal. Openings in well cover watertight: ❑ Yes. ❑ No. Pump: ❑ Shallow well. ❑ Deep well. Length of drop pipe, feet. Pump capacity, gallons per minute. Located in: ❑ Basement.. ❑ Pumproom off basement. ❑ Pumphouse above ground. ❑ Pump pit. Pumproom properly drained: ❑ Yes. ❑ No. Pump mounting watertight: ❑ Yes. ❑ No. Type of storage: ❑ Pressure. ❑ Gravity. Capacity, gallons. Has bacteriological examination of water been made? E)Yes. ❑ No. If answer is "yes," give date 19_ Quality of water ❑ is ❑ is not satisfactory for human consumption. Installation ❑ does ❑ does not comply with approved exhibits, if any. Inspection made by: ❑ State. ❑ County. ❑ Local health Authority. Inspected by Date of inspection , 19_ ( rITIAE V RECD JAN 0 3 ZOOO Standard Septic System Disclaimer (attach to FHA Form 2573) This ceftiricatl9n. is-a,,statement regarding the materials used a d their condition as of the date inspected. The system can be R expected to function properly with reasonable care and maintenance. However, it should be noted that every septic system has limited Kapacl ty and cannot accept water usage In access of the rate that the b:. NT ystem Is able to leach the effluent back into the ground. Care should be taken to spread out and limit water usage as much as possible since each household's water usage needs are variable. This certification makes no claim as to the systems ability to handle specific volumes of water Introduced Into the system. It makes no claim as to the condition of the sewer lines or the function of the plumbing units connected to those lines. It Is recommended that the septic tank have regular scheduled maintenance every 2 to 3 years. 5a - (o go Ave, ZuAre LCL R" rte -- EC Sewer Service, Inc. dba Econo Sewer Service P.O. Box 192 Palm Desert, CA 92261. (760) 346-2793 Contractor's Lic. C-42 746159 AIA, 151- q -?1,-1A tJ APt, kn-40��-1 .CNK s ,r� sl�,,�(� ���� - a,