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Home My WebLink About058-170-015 EHS25-0032 3/6/25 Deadwood septic design formSSTTAANNDDAARRDD 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 058-170-015 Rhonda Berndt de Pineda for Phillip DeCann Oroville CA 95965 3 1500 .6 36 200 12 360 3/5/25 36 x 3720 Deadwood 600