HomeMy Public PortalAbout10214 DAINES DR_Sewer__ E-6APPLICATION OR PE-R MI
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DIVISION OF BUILDING AND SAFETY SEWER-S EWAGP- DISPOSAL'
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER t ADDRESS f
® CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY '
FOR APPLICANT TO FILL: IN CROSS s.
LEGAL _
DESCRIPTION LOT NO OWNER' - ,:1t
MAIL
BLOCK TRACT47 ADDRESS
0. OF BLDGS. CITY TEL. NO.
SIZE OF 1.015h( NOW ON LOT '
USE OF
BUILDINGS / -' TB-�" DISTRICT NO., GROUP MAP
CONTRACTOK •
,r j CONNECTION DATA
ADDRESS �r, 3 DEPTH JI -
Cl -Itt—
CITY I` - TEL NO r^v ,f MANHOLE REFERENCE UPPER
[]-STATE/
REGISTRATION NO. - ❑ CONY _
No. D GRIP. ION OF WORK FEE
TYPE OF CONNECTIO LENGTH FROM '
HOUSE SEWER CONNECTING-TFO - �" Y. CURB L. M.L. TO P.L.
PUBLIC SEWER Q $,
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD J P, C. N0.
EXTN ,CESSPOOL,DRYWELL,MAN HOLE Q $2 00 CO, IMP. NO. / Q JOB NO
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM Q $1 00 _TRUNK PERMIT NO. ROAD PERMIT NO _
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT - -
WORK TO HOUSE SEWER Q $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 S 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
r-
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON- APPROVALS DATE INSPE OR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
TO THE PUBLIC S NEW HOUSE SEWER
SIGNED THIS AY F o 19� CONNECT ADDITIONAL
OWNER OR ) BUILDING OR WORK'
OWNERS AGENT / SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYW ELL,[]
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 ASREQUIREDBY LOS ANGELES COUNTY AND STATE OF ABANDON HO USE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBEDtRESIDENT k PR ERTY BACKFILL SEPTIC TANKS❑
SIGNATURE'II SEEP PIT(s) L1CESSPOOLS[I
OF PERMITTEE
JOHN A I_Am , C NTY 171AGINEER VALIDATI ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N O CASH
L,CO 4 c" 11'1126 0 A 5.00 �°
D
5&E-683 ft-68 APPLICATION FOR PERMIT - 1
8&E•8 -
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® - CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS s.
LEGAL'
DESCRIPTION LOT NO. OWNER /
MAIL
BLOCK TRACT ADDRESS
NO. OF BLKS CITY TEL. N0.
SIZE OF LO NOW ON LOT
USE OF I
BUILDINGS BK DISTRICT NO. I GROUP MAP
PG
CONTRACTOR
,�_ J„ CO TION DATA ADDRESS ,10'YZyfJ �3�J
STATION a !! DEPTH 011
CITY TEL. NO
n( MANHOLE REFERENCE .f UPPER
STATE
REGISTRATION NO ❑ COUNTY ! L
NO DESCRIPTI N OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO + Y. CURB P L M.L.TO P.L.
PUBLIC SEWER @ $3.99
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD CO IMP. NO. /y J
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $ 2 00 OB NO.
HOUSE SEWER CONNECTING TO - -
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO - ROAD PERMIT NO.
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 $
00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DA PELT R S GNATURE
TRACTOR'TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED TRI$ DAY OF 19 CONNECT ADDITIONAL Ny
OWNER
OWNER OR 1�(1(, BUILDING OR WORK
OWNERS AGE/ t SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR 1
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM,
1 HEREBY CERTIFY" THAT I 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 AM THE L GAL OWNER OF THE ABOVE
DESCRIBED RESIDENT PRO RTY. BACKFILL SEPTIC TANKS❑
SIGNATURE I SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE ppp�TT _
JOHN A LA C NTY GINEER ' VALIDATION ROBERT A.WOOD, CHIEF PLBG INSPECTOR
CK LACO M O N 0
CASH tIl MAR 2 6 1 0 A 5,•0O NI