HomeMy Public PortalAbout10414 DAINES DR_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES BUILDING
WILLIAM J. FOX, COUNTY ENGINEER ADDRESS �Id / 44V1,11
FOR APPLLICANT,,TO, ,F.ILL IN . LOCALITY c
nv
BUILDING NEAREST CROSSST
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST ' r
CROSS ST f Q, Q L�
�, RE VED BY Ready for Inspection DAT ISSUED
OWNER A
MAIL
ADDRESS USEZONE A
CCUPANCY BK MA P
CITY TEL.NO. f / I C
CONTRACTOR Cil t ro CO.IMP NO.
ADDRESS Z �) �}��r-��-, JOB.NO.
CITY (� �� TEL.NO. TRUNK PERMIT NO.
REGISTRATION NO !� STATE
� COUNT_Y ROAD PERMIT N0.
LEGAL LLSTATE ENCROACHMENT
DESCRIPTION LOT N0. dw PERMIT NO.
BLOCK TRACTX'�V. 4 41, 6 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT0 NO OF BLOGS. /
NOW ON LOT CHARGES
USE OF 1.'
BUILDINGS yT I CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER 0 $ 350 I RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 ) 0 --)
CONNECT ADDITIONAL BLDG.OR I EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00 NO
ALTER OR REPAIR EXISTING I DATE I 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/ORDRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 ( MANHOLE REFERENCE
I - UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
Y CURB P L. M L TO P L
OWNERS PERMIT $ I I
AUTHORIZATION I TOTAL FEE 1 4,' In/-,
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORSSaGNATURE DATE
DWELLING-TO THE PUBLIC SEWER 1
SIGNED THIS ....... .......DAY OF..... ...._..... NEW HOUSE SEWER �,�� �/)-,,
OWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
OWNERS AGENT_ _._______..___ .-_.----_.-_-__-_..................._._ SEPTIC TANK,SEEP.PIT(S) 5 1
ADDRESS-- - ------ -----•---•-•--••- --.._..---- --- -- --. ____._.. AND/ORDRAINFIELD
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. BACKFILL SEPTIC TANKS
SIGNATURE Q, v ' 1 SEEP PITS)E] CESSPOOLS 0
OF PERMITTEE '-1 l - — __•--r--------1.-`----.-'�-------- -
76A642D 663 1/53
AINE 6D
'6 Q 883 12.54 APPLICATION' FOR PERMIT 1
P&ISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
_ WM.J. FOX, COUNTY ENGINEER ADDRESS '
CASSATT D. GRIFFIN, SUPT OF BUILDING, LOCALITY
FOR APPLICANT TO FILL IN NEAREST
LEGALy� CROSS ST.
C
DE RIPTION'A LOT NO- �i`�7 ` U10� � ' OWNER S
BLOCK TRACT MAIL j
_ ADDRESS
SIZE OF LOT NO OF BLDGS,
r i !T NOW ON LOT CITY TEL NO
c n
USE OF
BUILDINGS DISTRICT f10. GROUP MAP
BK PG
CONTRACTOR %
f✓
ADDRESS CONNECTION DATA
CITY STATION � C, DEPTH q'
(� ❑ STATE MANHOLE REFERENCE -7
REGISTRATION NO
[3 COUNTY ¢ LOWER
V _ TYPE OF CONNECTION- LENGTH FROM ..r 1
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO �•)
PUBLIC SEWER @ $ .3 50 V
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR L CO. IMP NO / CJ �/ JOB NO WORK TO HOUSE SEWER 1 00 � >�
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT $ 00
AUTHORIZATION TOTAL FEE / REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
70 THE PUBLIC ER Jf e�4�a� NEW HOUSE SEWER .+
SIGNED THIS DAY OF - '� 14._� r 00
OWNER K OI, ��;' �yp �'� CONNECT ADDITIONAL
OWNERS„ AGENT _-�'I� �— �./�Yd' _ BUILDING OR WORK
ADDRESSxSEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS P CATI 'or 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 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 AM THE LEGAL ER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ //1�
- SEEP.PIT(S) ❑ CESSPOOLS (�
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
;gCo4 3- t ,Nu 3 4 6.5 O.s-�
,.BY BY / -
DEPUTY _ y('} J - DEPUTY -
' BY BY
DEPUTY DEPUTY