HomeMy WebLinkAbout065-340-030 EH-SE-25-000030 SITE EVALUATION APPLICATION, 1 BDRM ADUButte County
This
section
completed by
applicant
PUBLIC HEALTH
EH
Staff or
Certified
Designer
APN #:
Applicant N me
City,
Elte Elcaesiac and Septie
li Address ise
SITE EVALUATION FOR NEW DEVELOPMENT
Applicant Telephone Number
ON-SITE WASTEWATER
Way
Evaluation for: Residential use Commercial use
Nane of Certified Designer (if appBicable):
Zip
Parcel Size:
APPLICATION
Directions to site attached and site flagged *
Number of bedrooms or parcels (or description of intended use if non-residential):
-and one of the following -
-or
Efective soil depth:
Ngyrte of Certified Instaler (f applicable): ee Gongalrs
Site Evaluation application complete and fees paid *
Z Site pian attached (use checkiist inciuded in this appiication) *
acres
Traklt #:
Test holes excavated in manner described in On-Site Manual *
Neal orou
Proparty wner Name (4445
Slope in drainfield area:
inches
Sitg Evalu ion Parcel Address
City
Type of restrictive layer: 1 Impermeable
Horizontal setback requirements can be met:
Soil log data attached:
Official Use Only Do Not Write Below This Line
O Yes
O Yes
Certified Installer/Designer will contact staff to schedule site inspection and soil evaluation *
Items that must be completed before on-site evaluation takes place
OBSERVED SITE CHARACTERISTICS OF DISPERSAL SYSTEM PLACEMENT AREA
%
Gemwuod De.,
Date paid:
State
O No
Amount:
O No
Receipt No.
Slope in repair area:
Form SE
O Seasonal groundwater O Excessively drained O NJA
O Need scaled site plan
Zip
%
Update: January 28, 2015
065-340-030 EH-SE-25-000030
11.10.25
$210.25
201853
This
section
completed by
Environmental Health
Staff or
Certified
Designer
Site Evaluation
Page 2
O NIA, no additional testing required for completion of this evaluation
O Additional test holes required
O Percolation testing required (Site Evaluation cannot be completed until this task performed)
O Seasonal groundwater monitoring required (Site Evaluation cannot be completed until this task performed)
Wastewater System Type
O Standard Gravity
O Pressure Distribution
(After additional testing has been completed, attach RESULTS.)
ADDITIONAL TESTING
Dispersal System Requirements
Minimum vertical separation
Depth of curtain drain
System Designer
EVALUATION RESULTS
ONon-Standard Gravity
Application Rate gpd/ft? based on: O Soil texture ] Percolation rate J Soil data from original map
O Supplemental Treatment O Disinfection or engineered fill
Environmental Health Specialist
Special Design Considerations/Comments
Determination when Designer Required
I have determined that an onsite wastewater sys
tem for this site can be designed and approved
meeting the requirements of Butte County Code
Chapter 19 and the Butte County On-Site
Wastewater Manual provided the design parame
ters specified in this Site Evaluation are utilized.
Traklt #:
inches
inches
Date
I have reviewed this site in conjunction with the
Certified Designer and concur with the Designer's
assessment as certified above.
Date
O NIA, curtain drain not required
Determination when Designer Not Required
I have determined that an onsite wastewater system for
this site can be designed and approved meeting the
requirements of Butte County Code Chapter 19 and the
Butte County On-Site Wastewater Manual provided the
design parameters specified in this Site Evaluation are
utilized.
Environmental Health Specialist Date
Note: This Site Evaluation may be invalidated should one
of the following occur: (1) The type of use will be differ
ent than what was indicated in this application, (2) Site
conditions are altered, adversely impacting the drainfield
or reserve areas, or (3) New information becomes availa
ble clearing indicating the that findings or conclusions of
the Site Evaluation were incorrect and an adverse impact
to water quality or public health would result if the evalu
ation was not altered or invalidated.
Update: January 28, 2015
This
section
compl ted by
applicant
domers name
Assessor's Parcel Number
North arrow
SITE EVALUATION SITE PLAN CHECKLIST
Property lines
Any relevant site features such as cliffs, cut banks, irigation canals, springs, rock outcrop, iandsilide areas, drainage ways, etc/
Any existing and/or proposed site improvements, such as wells, buildings, pools, driveways,
etc. (please specify whether existing or proposed)
0,Existing wastewater dispersal areas, if present
Proposed primary and repair wastewater dispersa! areas
d Test hole locations (if already excavated at the time of application
Update: January 28, 2015
SITE PLAN
I certify th¡t the nformation in this :ite plan is accurate
ond complete, to the best of myknowle dge.
Sigrature
Owner Name:
Assessor's Parcel Nunber: DJ0-000-000 Pemit #:.
Site Location:
Date
Mocr
Same
Contact Name:Steve
Address / Phone: 42S Ckennood De Maça ia
Repkenene
Gonales
Reelaeme
Aome Porch
Scale 1" =
CA
PRapse
A
Phone:
Deisesay
Nes System
Eristing
System