HomeMy Public PortalAbout10525 DAINES DR_Sewer__ -61
76A6423-61
APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fA
UILDING 4
JOHN A, LAMBIE, County Engineer DDRESSWILLIAM A. JENSEN, Supt of Building OCALITY
EAREST
7FORUCANT TO FILL IN ROSS ST.
LEGAL
DESCRIPTION OWNER
BLOCK MAIL
ADDRESS IVNO OF BLDGS.SIZE OF LOTNOW ON LOT CITY' TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
f J`` BK PG
CONTRACTOR S U
ADDRESS CO CTION DATA
nt—
CITY TEL.N0. y STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
NO. 1 DESCRIPTIDWOF _WORK FEE
PUBLIC EWERSEWECONNECTING TO @ $S 00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M L.TO P.L
PITS AND/OR DRAINFIELD @ $S 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00 CL
HOUSE SEWER CONNECTING TO j/ P C NO. O
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO �7 JOB NO V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. �-'
WORK TO HOUSE SEWER St 00
SEWER O 'ISPOSAAIANDL SYSTEN HOUSE @ $I 00 STATE ENCROACHMENT
O
PERMIT NO V
INDUSTRIAL W
Q_
WASTE APPROVAL N
CHARGES ?
OWNERS PERMIT E 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 566 REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE HEEINCON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIST NGAMED DWELLING APPROVALS DATE- INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIq D 19— NEW HOUSE SEWER
OWNER OR � CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESa SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I. HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL Ij
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEIII
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ST E OF ABANDON HOUSE SEWER
CALIFORNIA OR THA 1 AM THE L GAL OWNER OF TH ABOVE
DESCRIBED OR I BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE, A
C"�FiLM 0. ROBERTMEC A WOOD
CK. r 0. cAsx SUPERVISING MECHANICAL ENGINEER _