HomeMy Public PortalAbout10160 DAINES DR_Sewer__ E-663
IS&E68 11.55' APPLICATION FOR PERMIT
8&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTYENGINEER ADDRESS
® CASSATT O. GRIFFIN, SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL A OWNER
DESCRIPTION LOT N0. MAIL
�(
BLOCK TRACT �D '� ADDRESS �j
N0. OO1FLBLDGS. CITY TEL. N
SIZE OF LOT NOW ON LOT
USE OF DISTRICT N0. GROUP MAP
BUILDINGSAo BK PG
CONTRACTOR e. �
�. 7
ADDRESS &60CONNECTION DATA �
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CITY .� TEL. N0. 4/!I STATION DEPTH
Q[[Y MANHOLE REFERENCJ -
REGISTRATION N0. LI COUT TY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM C
HOUSE SEWER CONNECTING TO ® L.
M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $ 3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD a1BP. C. NO. 3
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $ 2.00 CO. IMP. NO. 8=M�?
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TK PER T NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATRUNE ENCROA ENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
A R G E S
CONNECTION C E FEE
OWNER'S PERMIT $ 1 00
"i 5"® REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPE�-TOR•S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19r
CONNECT ADDITIONAL
OWNER OR '/ BUILDING OR WORK
OWNERS AGENT•a /'1 !!s.- SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE LEGAL 0 NER OF THE ABOVE
DESCRIBED RESIDENTIAL P ERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP.PIT(S) C3 CESSPOOLS❑
OF PERMITT
JOHN A. LAMBIE. COOrYEN (NEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
0. CASH
_ ,:�8 1 0 4 r 'f 13 4 4.5 0 C1