PMT18-05347 City of Menifee Permit No.: PMT18-05347
29714 HAUN RD. Type: Residential Demolition
MENIFEE, CA 92586
MENIFEE MENIFEE Date Issued: 11/05/2018
PERMIT
Site Address: 30761 SHERMAN RD, MENIFEE, CA Parcel Number: 360-120-017
92584 Construction Cost: $300.00
Existing Use: Proposed Use:
Description of ABANDONMENT OF EXISTING 1000 GAL SEPTIC TANK FOR SEWER CONNECTION
Work:
Owner Contractor
HUMBERTO ADAME
30761 SHERMAN RD
MENIFEE, CA 92584
Applicant License Number:
HUMBERTO ADAME
30761 SHERMAN RD
MENIFEE, CA 92584
Phone: 9512695026
Fee Description QtV Amount($)
Building Permit Issuance 1 27.00
Demolition Permit 1 140.00
GREEN FEE 1 1.00
$168.00
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carried on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee.Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance,or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Bldg_Permit_Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
I hereby affirm under penalty of perjury that I am under provisions of with a licensed contractor(s)pursuant to the Contractors State License Law).
Chapter9(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class License No. By my signature below I acknowledge that,except for my personal residence
Expires Signature in which I must have resided for at least one year prior to completion of
improvements covered by this permit.I cannot legally sell a structure that I
WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by
❑1 hereby affirm under penalty of perjury one of the following declarations:I licensed contractors.I understand that a copy of the applicable law,Section
have and will maintain a certificate of consent of self-insure for worker's 7044 of the Business and Professions Code,is available upon request when
compensation,issued by the Director of Industrial Relations as provided for this application is submitted or at the following website:
by Section 3700 of the Labor Code,for the performance of work for which
www.lesinfo.ca.aov/calaw.html.
this permit is issued.
Policy# Date
PROPERTY OWNER OR AUTHORIZED AGENT
❑I have and will maintain worker's compensation insurance,as required by
section 3700 of the Labor Code,for the performance of the work for which ❑By my signature below I certify to each of the following:I am the property
this permit is issued.My worker's compensation insurance carrier and policy owner or authorized to act on the property owner's behalf.I have read this
number are: application and the information I have provided is correct.I agree to comply
with all applicable city and county ordinances and state laws relating to
Carrier building construction.I authorize representatives of this city or county to
Policy# Expires enter the above idobtified prop y for inspection purposes.
(This section need not to be completed is the permit is for one-hundred // '
dollars($100)or less '(�� � �Z21 Date
PROPERTY,OWNER OR AUTHORIZED AGENT
❑1 certify that in the performance of the work for which this permit is issued,
I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the worker's compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with those provisions. Will the applicant or future building occupant handle hazardous material or a
mixture containing a hazardous material equal to or greater that the
Applicant Date amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes VI No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES Will the intended use of the building by the applicant or future building
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guideli es
CONSTRUCTION LENDING AGENCY ❑Yes o
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is issued outer boundary of a school?
(Section 3097 Civil Code) ❑Yes EA40
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjury that I am exempt from the California Health&Safety Code Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the hazardous aterial reportin
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 oYes o
L
Business and Professions Code).Any city or county that requires a permit to Date s
construct,alter,improve,demolish or repair any structure,prior to its PROPERTY 6WNER OR AUTHORIZED AGENT
issuance,also requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the Contractors State EPA RENOVATION,REPAIR AND PAINTING(RRP)
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painting(RRP)Rule requires contractors
Business and Professions Code)or that he or she is exempt from licensure receiving compensation for most work that disturbs paint in a pre-1978
and the basis for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applicant for a permit subjects the applicant to a civil penalty of not more required practices.This includes rental property owners and property
than($500). managers who do the paint-disturbing work themselves or through their
❑1,as owner of the property,or my employee with wages as their sole employees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.epa.gov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(5323).
Code;The Contractors State License Law does not apply to an owner of a ❑An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employees'or personal effort,builds or improves the
property provided that the improvements are not intended or offered for Certified Firm Name:
sale.If,however,the building or improvement is sold within one year of Firm Certification No.:
completion,the Owner-Builder will have the burden of proving that it was
not built or improved for the purpose of sale. ❑No EPA Lead-Safe Certified Firm is required for this project because:
❑I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors State License Law does not apply to an owner of a If your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION NNFEE
DATE: PERMIT/PLAN CHECK NUMBER
GRADING PLANNING CASE NUMBER OTHER RELATED CASES
C MULTI-FAMILY MOBILE HOME C) POOL/SPA SIGN
TYPE: COMMERCIAL AkESIDENTIAL
SUBTYPE: ADDITION ALTERATION DEMOLITION ELECTRICAL MECHANICAL
%::) PLUMBING C:. RE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK Ab&nAmnQ-,,*
OCCUPANCYGROUP CONSTRUCTION TYPE SPRINKLERS YES C) NO
ASSESSOR'S PARCEL NUMBER -360-10-*%0- LOT TRACT
ADDRESS
PHONE CIO EMAIL
APPLICANT NAME /0 ef
ADDRESS
PHONE -A EMAIL
CONTRACTOR'S NAME Z) OWNER BUILDER? YES C.:) NO
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION L SQ FT
DATE
APPLICANT'S SIGNATURE
OTYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION -7ACCEPTED BY: CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE
INVOICE TOTAL 1(0 GREEN -e-
NO
OWNER BUILDER VERIFIED YES NO DRIVERS LICENSE# NOTARIZED LETTER YES C)
City ofK8enifee Building & Safety Department | J9T14HaunRd, K8enifee (951)672-6777
�1
LAST UPDATE: 1/13/15
AC")?L> CERTIFICATE OF LIABILITY INSURANCE Month
Datc1Ycar
!s9Dnth•Dale Z'car
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
Insurncc kgent/Brokcr Name CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
Insurnce Agent/Broker Street Address or P.O.Box AFFORDED BY THE POLICIES BELOW.
Insurncc Agent/Broker Cih,State& Zip Code
Contact&Phone Number INSURERS AFFORDING COVERAGE NAIC#
------ --------- ---
INSURED INSURER A, \amr of In>umnce Company -ntcr,\AICg
INSURER B. UI Carriers must be rated A-VIII or better
Developer or De%cloper's Contractor Name
Street Address or P.O.Box Provide Insurance Carrier and AMBEST or NAIC#/
City,State&Zip Code
must be admitted -to be Verified by EMWD
COVERAGES:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS _
NSR ADD L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE LICY EXPIRATION LIMITS
OR t DATE PAMIDOrM DATE L"
A I® GENERAL LIABILITY Sec NOT E NI&42 LntcrLffecnixa EnlcrExpiration EACH OCCURENCE 5 I,000,
ENTE
Enter Police D
®COMMERICAL GENERAL LIA91L{TY DSIC Dal[ DAMAGE TO R PREMISES Ea omlrL el
t
i ❑❑CLAIMS MADE ®OCCUR Self Insured Retention(SIR) MED EXP(Any my person) s 5,000
I
❑ Must be Occurrence Type greater than S100 000 is PERSONAL A ADV INJURY s 1,000,000
❑ acceptable upon verification of GENERA AGGREGATE S 2.000,ow
GEN-L AGGREGATE LIMIT APPLIES PcR net-worth- If SIR applies,
must be nosed on certificate PRODUCTS-COMP/OP AGG 5 2.0W,000
❑POLICY® T LOC Must be PROJECT
B AUTOMOBILE LIABILITY Enter Policy:; linter L-fli:on a L•nter L-xpiraDon COMBINED SINGLE LIMIT 5 1,000,003
®
(Each O="nce)
ANY AUTO Date Date
❑ALL OWNED AUTOS BODILY INJURY
❑SCHEDULED AUTOS Must include Policy# Verify dates (Per per—) 4 _El HIRED HIRED AUTOS on each peril of on all perils BODILY INJURY
❑NON-OWNED AUTOS insurance(GL,Auto, of insurance (Peraccdenq -
Workers Comp, PROPERTY DAMAGE
IJ Equipment Floater(if (Per amdent)
GARAGE LIABILITY aDolicable.Excess) Verify limits -EAACCIOENT
❑ANY AUTO EA ACC
FFtCESSNMBRELLA LIABILITY EACH OCCURRENCE SEnlcr Limit
A p� Sec NOTE#•J Later Lffccu%e Emcr Expiration
N OCCUR ❑CLAIMS MADE Date I Date AGGREGATE SEnlcr Limit
Later Policy 4
❑DEDUCTIBLE lifrcquircd)
❑RETENTION
WORKERS COMPENSATION AND WC STATU- OTH-
C EMPLOYERS'LIABILITY Sle NO t #3 Lnler Fffecihc Enter t:xpiration ®TORYLIMRS ❑ ER
ANY PROPRIETORIPARTNER'EXECU- Enter Pube y+- Date Date E L.EACH ACCIDENT 1,000,
TIVE OFFICERIMEMBER EXCLUDED7
u yes.desoihe under
E.L.DISEASE-EA EMPLOYEE S 1,000,20
SPECIAL PROVISIONS ne:rnr
E.L DISEASE-POLICY LIMIT S I,000
F
uipment: Sponsor ondror $ NIA
ntructor solCh responsible for N/A NIA NSA
ols,equipment&materials
DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES I EXCL IONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Project Name must be included on certificate
Include Project name&Tract N umbel,PPI number ' EMWD named a5 additional insured here
LOTE
EMWD named as additional insured per C _010(1 185)OR CG2010(10r01)'t'.ITH CG2037(10'
Per Project Aggregate limits per CG2503(Ar97).
%%ah cr of Subrogotion endorsement to't\orker's Compensation in fasor of F.NINt D. Endorsements must be attached.
Excess,Umbrella Iiahilit%can be used in connection eith priman liability insurance to equal amounts required.
CERTIFICATE HOLDER CANCELLATION
EASTERN MUNICIPAL WATER DISTRICT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
PI N DATE THEREOF,THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
Attn: New Business DSR Section MAIYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
P O Box 8300 FAILU E TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Perris,CA 92572-8300 INSURER,ITS AGENTS OR REPRESENTATIVES.
Must name EMWD Cancellation no longer list a date (30 days)
JOB DESCRIPTION SECTION ABOVE: NOTES 1-4 MUST BE STATED AND MUST SPECIFY THE
APPLICABLE ENDORSEMENT NUMBERS.
DATE:Octobcr 31,2018
** * * * S.O.#: 238995
DUPLICATE DUPLICATE DUPLICATE DUPLICATE FOR SERVICE DATED 09/12118—REVISED TO REFLECT NEW DUE DATE**
EMWD
MAIN OFFICE MUNICIPAL WATER DISTRICT
PERRIPO BOX g8300 8300 LICATION FOR SERVICE, CA
951-'928-3777 PROJECTNUMBER: 16757 E,.
PPIN: WS20140000167
Reg# #/Rcpt#: 001-00127592 CUSTOMER INFORMATION V
Accounting Date; Fri, Nov 2, 2018 PHONE:951-2 -5026
Gate/Time: Thu, Nov 1, 2018 4:31 PM CA92584 EMAIL:ADAMEELVIAir?YAHOO.COM
4T INFORMATION-ADAME HUMBERTO
SPORTCV CHECK -- SPORT/CITYVIEW CHECK I)RESS:30761 SHERMAN RD, MENIFEE,CA 92584
REF#:HUMBERTO ADAME S.0. #238995 TYPE: SINGLE FAMRLY DWELLING
SERP7CE
ACCl#:3100-26400-300010-0-000 IVNEC77ONLOCATION DEY/CONTRACTOR WORK ORDER
FEE AMOUN :` 18,304.00 W/S SHERMAN RD 'STAKE LOCATION OF FUTURE 4"SEWER LATERAL 238995
EL MOLINO VIEJO DR *INSTALL 4-SEWER LATERAL&
______________.-_.-_ CLEANOUT till PROPERTY LINE
RECEIPI TOTAL $ 18,304.00
SEWER INFORMATION
Payment Data: SEWER I.D.&A: U35!33
Pmt# :1 PIPESIZE&LOCATION:12"PVC
NO.OFUNITS.
Payer; HUMBERTQ ADAME S.O. • 2EDU TE.S30.
'S RA
TBG.86S-D4 WATER COMPANK ONA WELL
METHOD: CK $ 18,304.00 DX4WING NO.D-149S7
Ref#: 0901
FEE INFORMATION
kkl kl kk /f k *�kkkk kkk k k k ON ASSESSED TOTAL*
RECEIPT SUMMARY ArklOUN'r
70.00/ACRE 100.00/ACRE $98.00
TOTAL TENDERED $ 18,304.00 M.061ACRE 10000/ACRE 9800
RECEIPT TOTAL $ 18,304.00 ® 2EDu°S 2,768.00/EDU 5,536.00
IE 39000 390.00
CHANGE DUE $ 0.00 Dus 5.641.00/EDU 11,282,00
k �FklkkAkkk* # 300.00 30000
HAVE A GREAT DAY SO23899SQ?EDUS 300.001EDU 60000
DUPLICATE DUPLICATE DUPLICATE DUPLICATE $183oaofl
u:1.0.4858
INANCIAL PARTICIPATION CHARGES SET FORTH HEREIN ABOVE:
*This Application shall become null and void if it has not been executed on behalf of Applicant and District,and Applicant has not fulfilled
its financial arrangements as set forth herein above,concurrently with Applicant's execution of this Application,on or before
November 30.2018.
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Pagel of 3
Document 1D:3548061
Dip Y,
Date: 1 I i I/2018
EMWD Board of Directors
P.O. Box 8300
Perris, CA 92572-8300
SUBJECT. Annexation, of improvement District Nos. U35 & U35
To Whom it may conern:
in reference to the property(ies) listed below, please accept this letter as a formal request to annex
-ald parcel into Improvement District No(s).: U35 and U36
have submitted a payment of. '498.00s along with a copy of the grant deed to the property. (If
individual name is not on Grant Deed(i.e., corporation),please furnish documentation authorizing
signator(s)).
Maifing Address: 30761 SHERMAN RD, MENIFEE, CA 92584
' iA BD, €a�viBFEE, CA g258INI�ys
acne No- (951) 259-5026
mail Address: ADAMEEtra4 e0GMAEc..COP-At
"orttact Narne's).HUMBER O & ELVIA Ai AME
C Owners (if appiir ia% L: NIA
(Please furnish documentation listing LLC owners and signator authority for the LLC).
APM(s)and/or Parcel Map or Tract No.: 360-120-017 PM: 16757
Payment Submitted:
No. of Acres: Fees
Sewer andIcir 16'a'er
0.98 $zss
Annexation Fee 6c��7_tJ�C,7rcrFs.
:Board of Equalization. $300.00
TOTAL. FEES: $498.00
(Signature)
(Print Name)
Improvement District(s): U35 & U36
Page I
DATE:October 31,2018
S.O.#: 238995
**REVISED—REPLACES APPLICATION FOR SERVICE DATED 09112118—REVISED TO REFLECT NEW DUE DATE**
EASTERLY MUNICIPAL WATER DISTRICT
APPLICATION FOR SERVICE 1,
PROJECT SE NUMBER:3646909 PROJECT NUMBER: 16757
LOTNUMBER(S):2 PP19: WS20140000167
CUSTOMER INFORMATION
CUSTOMER/COMPANYNAME.HUMHERTO ADAME PHONE.951-2a9-5026
AfAILING ADDRESS.30761 SHERMAN RD.MENIFEE,CA 92584 EMAIL:ADAMEELVIA-ediYAHOO.COM
PROJECT LOT INFORMATION-ADAME HUMBERTO
APN:360-120-017 ADDRESS:30761,SHERMAN RD, MENIFEE,CA 92554
TENANT TYPE:SINGLE FAMILY DWELLING
SER HCE
EMWD WORK CONNECTIONLOCATION DEVICONTRACTOR WORK ORDER
'OBTAIN FOOTAGE FOR FUTURE SEWER LATERAL W/S SHERMAN RD °STAKE LOCATION OF FUTURE 4"SEWER LATERAL 238995
�INSPE-Ci 4"SEWER LATERAL AND S/EL MOLINO VIEJO DR °INSTALL4"SEWER LATERAL&.
CLEANOUT AT PROPERTY LINE CLEANOU T u0 PROPERTY LINE
WATER INFORMATION—N/A SEWER INFORMATION
WATER LD✓SA: SEPVER I.D./SA: U35 f 33
PIPF'SIZE&LOCATION: PIPE SIZE&LOCATION:1211 PVC
0 DOMESTIC RATE I BOOK PIO. NO.OF UNITS: 2 EDU S RATE:S302
® 117RIGATI0NRATE TBG: TBG:869-D4 I W4TER COMPANK GIVA WELL
DRAWING MO: ZONE: Dk4WING NO:D-149S7
FEE INFORMATION
ASSESSEEB
FEE DESCRIPTION Ar*IOUN'i' TOTAL*
ANNEXATION REQUEST— SEWER U-35 .98 ACRF,9 S100.60/ACRE 100 001ACRE —$98 00
ANNEXATION_REQUEST— WATER U 36.98 ACRES®S100.001ACRE 100 00/ACRE 99 00
SEWER FINANCIAL PARTICIPATION CHARGE:SO?39995®2 EPU`S 2,768.00/EDU 5,536.03
SEWER LATERAL CONNECTION WSPECTION @ MAINLINE 39000 _ 39000
SEWER TREATMENT PLANT CAPACITY SO 238995@ e EDU S 5.641.00/EDU 11,292 00
STATE BOARD OF EQUAL(LESS THAN I ACRE) 30000 30000
WATER SUPPLY DEVELOPMENT FEE FOR RESIDENTIAL:SO 238995@ 2 EDUS 300.00/EDU 60000
Totat $1"04 00
DISCLOSURE REGARDING FINANCIAL PARTICIPATION CHARGES SET FORTH HEREIN ABOVE:
*This Application shall become null and void if it has not been executed on behalf of Applicant and District, and Applicant has not fulfilled
its financial arrangements as set forth herein above,concurrently with Applicant's execution of this Application,on or before
November 30.018.
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Pagel of 3
Doetentsne 1®:3643651
DATE: 10/31/18
EASTERN MUNICIPAL WATER DISTRICT
APPLICATION FOR SERVICE
ALL STANDARD METER/SERVICE INSTALLATIONS BY DISTRICT FORCES:
Eastern Municipal Water District's(EMWD) Standard Hydrant/Meter/Service installations fees are based on labor, equipment, and material for a standard
installation.The fees do not take into consideration any non-standard conditions such as traffic control.asphalt,hard soil or conditions set forth by county or
City Agencies. Any non-standard conditions may require additional payment to proceed with installation(s). Applicant will be advised of such conditions
and additional funds required to proceed. Applicant has the right to cancel request upon receipt of such notification.
Pressure and Supply: District assumes no responsibility for loss or damage because of lack of water or pressure and merely agrees to furnish such quantities
and pressures as are available in its general distribution system.The service is subject to shutdowns and variations required by the operation of the system. it
is each customer's responsibility to install a pressure regulation device when normal or high pressure exists at their point of connection to safeguard the
customer's water system fiom being affected by existing or future variations in the main line pressure. Where low pressure exists at the customers point of
connection,customer shall be responsible to install a pressure regulation device at such time when District makes modifications to distribution system where
pressure converts from Low to Normal or High. Where a remote temporary water service installation is installed,customer shall be responsible at the time
of future relocation to install a pressure regulation device.if at such time Normal or High pressure exists at new point of connection.
Customer Initials
ALL SERVICE CONNECTIONS(ITEMS MAY OR MAY NOT APPLY):
® EMWD to inspect sewer connection. Customer to contact Inspection Department 48 hours in advance at(951)928-3777 ext.437-2.
® Customer to contact Field Engineering at (951) 928-3777 ext. 4830 to schedule pre-job meeting before any work by customer's
contractor.
❑ Propel-ty is in Special Area. Ni/A PER MAP VB
® SEWER SERVICE AGREEMENT: Sewer Service is subject to the EMWD's Federal EPA, State and Local regulations.
® SEWER BACKWATER VALVE: Section 710.1 of the Uniform Plumbing Code states that"....Fixtures which have flood level rims
located below the elevation of the next upstream manhole cover....shall be protected...by installing an approved type backwater
valve." If property meets this requirement customer is required to install, own, operate, and maintain, at customer's expense, an
approved backwater valve and agrees to hold the Eastern Municipal Water District harmless from or on account of any damages
arising from the failure of customer's backwater valve. Customer agrees to notify EMWD should the device overflow.
SUBMITTAL ITEMS BY CUSTOMER REQUIRED PRIOR TO OR AT TIME OF PAYMENT WITH THIS EXECUTED
APPLICATION(ITEMS MAY OR MAY NOT APPLY):
❑ INSURANCE CERTIFICATE: District insurance requirements must be satisfied prior to submitting Application and Application
Fees. **APPROVED INSURANCE RECEIVED 10124118 xx
® ANNEXATION (estimated site acreage of .98 to EMWD or I.D.prior to service. Customer to submit: PER TRAVIS H. 07/27/15
1. A Letter to Eastern Municipal Water District's Board of Directors requesting annexation to Improvement District U-35 R U-36.
2. Copy of Deed to properties;and
3. Estimated Annexation Fees(calculated at$200/acre)and State Board of Equalization fee, both of these charges are included with
total fees due on Page-1-{Fees Section stinFate°is subject itional invoicing/refund upon final verification of actual acreage.
® OtherEALTH DEPARTNIENT APPLICATION FOR SEPTIC ABANDONMENT
Customer' s Signature: DATE: J
Print Name & Title: Q r, ✓r'
EMM' s Signature: ,` DATE:
iJ VANESSA BUENROSTRO
9 Page 2 of 3
DATE: 10/31/18
S.O.#: 238995
EASTERN MUNICIPAL WATER DISTRICT
APPLICATION FOR SERVICEIr
'
Comments: ADAME HUMBERTO
rx REVISED—REPLACES APPLICATION FOR SERVICE DATED 09/12/18—REVISED TO REFLECT NEW DUE DATE Y-
2-MANUFACTURED HOMES WILL CONNECT TO EXISTING 12"PVC SEWER LINE AND NEW 4"SEWER LATERAL WILL BE
r INSTALLED TO SERVE BOTH MANUFACTURED HOMES. CLEAN-OUT REQUIRED AT PROPERTY LINE.
PROPERTY MUST ANNEX INTO ID 85 FOR SEWER AND ID 86 FOR WATER.
EXISTING WATER SERVICE TO THE PROPERTY,PROVIDED BY A WELL.
PRE-CON MEETING REQUIRED,LICENSED CONTRACTOR WITH CLASS A OR C:34 TO PERFORM WORK IN THE RIGHT-OF-WAY.
Prior to construction, applicant must verify the existence and location(s) of water service line(s)/sewer lateral(s). Applicant hereby agrees
to hold the District harmless from or on account of any damages arising in cases where the water service lines)/sewer lateral(s)cannot be
located. If water service line(s)/sewer lateral(s) represented on EMWD's maps cannot be located, applicant must make arrangements to
construct new water service line(s)/sewer lateral(s).
Customer' s Signature: r� Q DATE: �' —�j -1
Print Name S: Tit e: �Y�
ENWD' s Signature: DATE:
f
VP_,MSSA BUENROSTRO
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