HomeMy Public PortalAbout10150 DAINES DR_Sewer__ D
IS&E-S8APPLICATION FOR PERMIT - 1
8$E 8DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los AngelesBUILDING /- O
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
I NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT a 2,4 3 1? ADDRESS
NO. OF BLDGS. / CITY - TEL. NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS -
.DISTRICT NOGROUP - MAP
BK PG
CONTRACTOR � ���y 0(- ,
ADDRESS -Z v#..4 CONNECTION DATA
CITY TEL. N0. qve S STATION Q DEPTH ,
MANHOLE REFERENCE PPER
REGISTRATION NO / Z / COUNTY `
NO ,DESCRIPTION OF WORK FEE a ,
TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO / p L. M L. TO P.L.
PUBLIC SEWER @ $3 SO �j )
SEPTIC TANK,SEEPAGE PIT OR
_PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO. IMP. NO. J,✓3Si{O.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK P RMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR STATE ENCR NT
WORK TO HOUSE SEWER Q $100 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 o0
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE d
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER • NEW HOUSE SEWER
SIGNED THISDAY F CONNECT ADDITIONAL
19
OWNER OR �i/. BUILDING OR WORK
OWNERS AGE N SEPTIC TANK,SEEP;PIT(S)
'ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY, ORDINANCES ANP STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA PERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS) ❑ CESSPOOLS❑
OF PERMITT
Ed
JOHN A LAMBIE, NTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK Y 0 CASH c
4
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