HomeMy Public PortalAbout10400 DAINES DR_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITYBUILDING
x NEAREST
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ADDRESS CROSS ST. O !v'
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
C
NEAREST
CROSS ST. -��'O �✓ �� S
REf:E1VE Y i"
OWNER Ready for Inspection DATE ISSUE
11.G� � �.�,t.af � ��
MAIL / �6 W USEZON / OCCUPANCY
ADS 6 /(�� 1{F L�'i�wt••a`RG BK PG
CITY TEL.NO.r�_ �� I OBJ
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CONTRACTOR
CO.IMP.N0.
ADDRESS
JOB NO. — — --
CITY — TEL.NO. TRUNK PERMIT N0. --- --—
STATE
REGISTRATION NO. _ H COUNTY ROAD PERMIT NO.
LEGAL ESB STATE ENCROACHMENT
DESCRIPTION LOT NO. '"/ PERMIT NO.
BLOCK TRACT •' ft !f /f-f� _( INDUSTRIAL
WASTE APPROVAL --
SIZE CF LOT NO.OF BLDGS.
NOW ON LOT / CHAR 8
USE OF
BUILDINGS CONNECTION CHARGE E
NO. DESCRIPTION Me WORK FEE
HOUSE SEWER CONNEC ING TO REIMBURSEMENT FEE
PUBLIC SEWER 40 $ 3.50 - RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/0RDRAINFIELD 2.00 STATION DEPTH j, "Y DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 — / MANH REFERENC
Z PE$ LOWER
TYPE OF NECTIOLENGTH FROM
OWNERS PERMIT $ 1 00 ���i M.L.TO P.L.
AUTHORIZATION I TOTAL FEE S�
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWE APPROVALS INSPECTOR'SSIGNATURE DATE
SIGNED THIS---------_ -----_DAY OFA_................... NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT..-------- ZT►.�/.:_..... --.......................... BUILDING OR WORK
./ SEPTIC TANK.SEEP.PIT(S)
ADDRESS-------------------------------------- 1ti--- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILLSEPTIC TANKS
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SIGNATURE SEEP.PIT(S)E] CESSPOOLS
OFPERMITTEE.-'.---' --•--------------------------............................ -
96A642D 663 1/53
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