HomeMy Public PortalAbout10523 DAINES DR_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEDER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
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�( WILLIAM J. FOX, COUNTY ENGBUILDINGINEER I ADDRESS
LOCALITY
BUILDINGFOR APPLICANT T ILL IN.. T C.
BUILDING NEAREST
ADDRESS CROSS ST!
LOCALITY DISTRICT N0. SERIAL NO. 1 PERMIT NO.
NEAREST I A !�09 2 S
CROSS ST ,
RECEIVED BY Ready for Inspection DATE ISSUED
OWNERMAIL 1 (7L-.Y C/4,L
ADDRESS - USE ZONE OCCUPANCY BK MAP PG
CITY T�ELNO. ---
CONTRACTOR
` CO.IMP.NO. 14-50 —4—
ADDRESS O JOB.N0,
C TE,�LAO. STATE TRUNK PER11ST NO.
REGISTR ION NO (J ® COUNTY;
ROAD PERMIT N
LEGAL � pERMiT 'NT LOT NOO
BLOCK TRACT INDUSTRIAL /
WASTE APPROVAL
SIZE OF LOT N0.OFBLDGS. y- CHA ES
NOW ON LOT
BUE DINGS CjjJQ�f J CONNECTION CHARGE FEE -OF 1- _
NO. DESCRIPTION OF WOWK' FEEV REIMBURSEMENT FE `
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 O RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO _i• /s:
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG.OREXCEPTION RECORDED \
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO 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 _ y
PITS AND/OR DRAINFIELD 2.00 STATION .� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2 00Q- MA EFERENCE
CUPPER I-' _L&W&R- /
TYPE OF CONNECTION LENGTH FROM c� /
Y. CURB PL. / M L TOPL
OWNERS PERMIT ; I 00 -
AUTHORIZATION I TOTAL FEE _5_
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I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED ,
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE -
SIGNED THIS-----------DAY OF. .-- .-.-_---..------__-- --. 19.__._ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL U
OWNERS AGENT- _ _ BUILDING 6R WORK
- lI -
fD SEPTIC TANK,SEEP.PIT(S)
ADDRESS _- _: _ __ ____ __..__ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A'PPLI- CESSPOOL E] 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 THATRI AM PROPERLY REGISTERED DISCONNECT PLUG AND
LAND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSESEWER
ND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
R OF THE ABOVE ESCRIBED R ENTIAL PROPERTY. BACKFILL SEPTIC TANKSGNATURESEEP PIT(S)E] CESSPOOLS a �G a C.FP
ERMITT - .�-- - ___.. .-
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