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HomeMy WebLinkAbout073-320-040 EHS24-0337 NEW SEPTIC APPLICATION 2 BEDThis section completed by applicant APPLICATION Form CP APN #: TrakIt #: Applicant Name (Please print) Property Owner Name Applicant Mailing Address Construction Site Address City State Zip City State Zip Applicant Telephone Number Certified Designer (if applicable) ☐New Construction ☐Repair ☐Expansion ☐Tank Destruction Certified Installer (if applicable) ☐Tank Replacement Only ☐Residential: Number of bedrooms: ☐Non-Residential (specify): Applicant Signature Date DESIGN AND CONSTRUCTION APPROVAL This permit is issued based on review of the attached design and has determined that it meets the re- quirements of Butte County Code Chapter 19 On-Site Wastewater Systems. _ _ Environmental Health Specialist Date of Issuance Comments/Conditions: � This permit valid only for installation of attached design, stamped “Approved.” Variation from the ap- proved design must have prior approval by Environmental Health. � This permit valid only if system is installed by the homeowner or by a contractor with valid Installer Certification issued by Environmental Health. � This permit will expire 2 years from the date of Design and Construction approval. This secti FINAL APPROVAL AND CERTIFICATE OF Installation by: ☐ Homeowner ☐ Certified Installer ☐ As-Built Attached ☐ Designer Sign-off Inspected by: Comments: _ Environmental Health Specialist Date White – Environmental Health copy Yellow – Customer copy: Final approval Pink – Customer copy: Permit Update: December 14, 2020 on completed by Environmental HealthON-SITE CONSTRUCTION P Date: _ Amount: Receipt No. This application will be accepted with payment of permit fee and the permit will be issued when system design is submitted by a Certified Designer (or Certified Installer for Standard Gravity System) and approved by Environmental Health. 073-320-040 Magneson Tractor Service, Inc.Lance Dorman 073-320-040PO Box 297 Paradise Ca 95967 Oroville Ca 95966 530-961-3171 Levi Magneson 2 12/05/24 SSTTAANNDDAARRDD GGRRAAVVIITTYY SSYYSSTTEEMM DDEESSIIGGNN FFOORRMM Update: September 12, 2014 Staff Use Only Date Received: __________ Staff: __________________ A design will be reviewed when this form and the design drawings are submitted with an On-Site Wastewater System Construction Permit application and fees are paid. Parcel Identification APN #: ______________________________ ______________________________________ Applicant Name ______________________________________ Parcel Address ______________________________________ City State Zip ______________________________________ Subdivision Name/Division/Block/Lot TrakIt #: ______________________________ ______________________________________ Designer Name ______________________________________ Designer Mailing Address ______________________________________ City State Zip ______________________________________ Designer Telephone Number Design Parameters Dispersal Type: Drainrock Chamber Polystyrene Number of Bedrooms _____________ Daily Flow (gpd) __________gpd Septic Tank Capacity ___________gal Application Rate ________gpd/ft2 Designed Vertical Separation ________inches Ground Slope in Drainfield Area __________ % Drainfield Square Footage __________ Trench Width _____ inches Total Lineal Trench Length _________ ft Trench Depth _____ inches Depth of Fill over Drainfield (if applicable) _____ inches Curtain Drain Depth (if applicable) _________ f Certification of Design The undersigned Certified Installer or Certified Designer (circle one) has submitted this design based observed site conditions as shown on this design form and the drawings attached thereto. _________________________________________ System Designer Date The undersigned has reviewed this design on behalf of Butte County Public Health Department and determined it to be in compliance with state and local on-site regulations and ordinances. _________________________________________ Environmental Health Specialist Date Caution: This design approval is only valid when all the following conditions are met: The design is stamped “Approved” by Butte County Public Health Department The Wastewater Construction Permit has not expired; the Permit Expiration Date is 2 years from the date of issuance The system is installed by a certified installer or homeowner authorized by the Butte County Public Health Department Drainfield site conditions have not been altered to adversely affect conditions of design approvalThis section completed by Certified Installer or Designer This section completed by EH Form DG 073-320-040 Magneson Tractor Service, Inc 073-320-040 Oroville Ca 95966 2 1500 187 36 12/05/24 530-961-3171 Same as applicant 240 561 18.3