HomeMy Public PortalAbout10166 DAINES DR_Sewer__ D
S&E-6 .69tl1•D'J - APPLICATION FOR PERMIT
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'DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL i■
Deportment of County Engineer .
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS /D
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
FOPPLICANT TO FILL IN c....S
R A
LEGAL r OWNER
DESCRIPTION LOT NO Aczlell.� I/
MAIL
BLOCK TRACT ADDRESS '
SIO X , ZO N0. OF BLDGS , 'CITY TEL NO <
SIZE OF LOT�(TJ NOW ON LOT
USE OF _
BUILDINGS DISTRICT NO.,, GROUP MAP
�c -BK PG
CONTRACTOR .✓ ��' ��
CONNECTION DATA
ADDRESS"
STATION -�j SdDEPTH%
CITY TEL. NO
❑ STATE MANHOLE REFERENCE
' r
OWE
REGISTRATION NO. ❑ COUNTY ,
No DESCRIPTION OF W RK FEE
HOUSE SEWER CONNECTING TO Q J� Y.-
_ TYPE OF CONNECTION LENGTH FROM /
PUBLIC SEWER @ $3.50 3 �+ Y' CURB P L M L TO P L �
SEPTIC TANK,SEEPAGE PIT OR `
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD Q P. C NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO -/ JOB NO
,HOUSE SEWER CONNECTING TO /,/�,
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO 7/ 6
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE •�
OWNER'S PERMIT 1 00
REIMBURSEMENT FEE
AUTHORIZATIO_N TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED,THIS D Y OF 19 CONNECT ADDITIONAL, ,
OWNER OR IA� - BUILDING OR WORK „
OWNERS AGENT •� U r SEPTIC TANK,SEEP, PIT(S) '
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIR BY LOS ANGELES COUNTY AND STATE OF .ABANDON HOUSE SEWER
CALIFORNIA OR T T AM THE LEGAL OWNER OF 'THE ABOVE -
DESCRIBED RESID TI ROPERT BACKFILL SEPTIC TANKS❑ -
SIGNATURE 'd r SEEP.PIT(S) ❑ CESSPOOLS[3 '
OF PERMITTEE J ,
rdliamw MAN3 � 4
JOHN A. LAMBIE, COUNTY*E ]NEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR-
CK. 61 0. CASH -
` Z 9 425�' :.fit,'.