HomeMy Public PortalAbout10525 1/2 DAINES DR_Sewer__ -61
76A6423-61
APPLICATION FOR PERMIT
8A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building_ LOCALITY
NEAREST •-
FOR APPUC T CROSS ST.
LEGAL r _ /
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP BK MAP PG PROCESSED BY
� _
CONTRACTOR r 5" y-
.
ADDRESS Sl CONNECTION DATA
CITY TEL N0. ST ION ` DEPTH )
R-ITATE 4ANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
NO. DESCRIPTION OF WORKFEE
PUBLIC SEWER CONNECTING TO @ $S 00 /
TYPE OF COE LENGTH FROM
SEPTIC TgNK,SEEPAGE PIT OR T. C P.L. M L TO P.L
ITS AND/OR DRAINFIELD @ SS 00
OVERFLOW SEEPAGE PIT DRAINFIELD 1'
EXTN CESSPOOL DRYWELL @ $2.00 d
HOUSE SEWER CONNECTING TO P C NO. O
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD
PERMIT N0. Ix
TO HOUSE SEWER S1 00 O
ALTER,REPAIR OR BA STATE ENCROACHMENT
SEWER OR DISPOS S OUSE @ $1
00 PERMIT NO V
INDUSTRIAL UJ
WASTE APPROVAL V)
CHARGES ?
OWNERS PERMIT S CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVAIoS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD f d®
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS-REGULATING ALTER REPAIR,SEWER OR
LESCRIBED
AND SEWERS. SEWAGE DISPOSAL SYSTE
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
OR THAT I AM TH LEGAL OWNER OF THE ABOVE
RESIDE L P LE BACKFILL SEPTIC TANKS ❑
SEEP PIT(S CESSPO LSTTE93
? t
�JJAI.IDA ONROBERT A. WOOD
Y o. CASH SUPERVISING MECHANICAL ENGINEER
f
76A642 D-81 APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING C
JOHN A, LAMBIE, County Engineer ADDRESS .J
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT IN CROSS ST.
12
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK 13 TRACTMAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF GS DISTRICT NO GROU BK PG MAP ESSED BY
BUILDIN
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO. TION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
No DESCRIPTION OF _ FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $5.00 TYPE OF CON C LENGTH FROM
SEPTIC TgNK,SEEPAGE PIT OR Y. C P.L. M L TO P L.
PITS AND/OR DRAINFIELD @ S8 00
OVERFLOW SEEPAGE PIT,DRAINFIELD }
EXTN CESSPOOL DRYWELL $2 00 C
HOUSE SEWER CONNECTING TO P.C N0. O
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER 51 00 O
12
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT `
PERMIT NO U
INDUSTRIAL 9L
WASTE APPROVAL
CHARGES Z
OWNWS PERMIT S 2 00 CONNECTION CHARGE FEE �^
AUTHORIZATION I TOTAL FEE r Lo D REIMBURSEMENT FEEHAVE AT
TMED CON- A
RACTOR TO CIONNECT THE ABOVE ESCRIBED EXWITH THE IST NGEIN ADWELL NG APPROVALS -DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. B
SIGNED THIS Y OF t9_ NEW HOUSE SEWER d� 71 4,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS 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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL Sy
STE
I 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 AM THE LEGAL OWNER OF THE BOVE
DESCRIBED RESIDENT L ROP BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS CESSPOOLS
OF PERMITTE
0caAMATION ROBERT A. WOOD
M o. CASH SUPERVISING MECHANICAL HNGINEER
EI