HomeMy Public PortalAbout10527 DAINES DR_Relocation__ -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 Enggineer ADDRESS r(oA �..
WILLIAM AAM
JENSEN, Supt of Bwlding LOCALITY A
NEAREST
FOR APPLIC T CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT NAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTACTOR
ADDRESS CONNECTION DATA
CITY TEL.N0. p, A ST ON DEPTH o-
STATE N NHOLE REFERENCE UPS`
REGISTRATION NO . COUNTY
NO. 1 DESCRIPTION OF _WORK FEE
HOUSE SEWER CONNECTING TO S/
PUBLIC SEWER @ $3.00 TYPE OF CONN ION LENGTH FROM
SEPTIC TgNK,SEEPAGE PIT OR Y C R P L M L TO P.L.
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL $2 00 d
HOUSE SEWER CONNECTING TOP C NO. O
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP NO JOB NO. (.J
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER 0
S1 TRUNK PERMIT NO ROAD PERMIT N0.
0
ALTER,REPAIR
DISPOSAL SYNTEN SE @ $1 00 STATE ENCROACHMENT Q
PERMIT NO
INDUSTRIAL
WASTE APPROVAL H
CHARGES Z
OWNERS PERM $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r REIMBURSEMENT FEE
NAMED CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXDATE A CONTRACT WITH THERISTNNG DWELLING APPROVALS 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 113
ADDRESS SEPTIC TANK,SEEP PIT(S) /
AND/OR DRAINFIELD
I 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 SYSTENI
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 1 AM THE LEGAL OWNER OF E ABOVE
DESCRIBED RESIDE T L 0 R�'T. BACKFILL SEPTIC TANKS
SIGNATURE T SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
�ATION ROBERT A WOOD
0.
cIL r 0. CASH SUPERVISING MECHANICAL ENGINEER
i'Ov 6
L
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-61
76A6423-61
APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION fBUILDINGJOHN A, LAMBIE, County Engineer DRESSS WILLIAM A. JENSEN, Supt of BuildingCALITYAREST
FOR APPLICANT O FIJ•L oss sr.
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
0 OF BLD S.
SIZE OF LOT NOW ON LOT z f
TEL NO
USE OF
BUILDINGS ICT NO GROUP MAP PROCESSED BY
CONTRALTO � BK PG
LI
ADDRESS C CTIO DATA
CITY L N0. • ION DEPTHAdREGISTRATION NO FVATE COUHOLE REFERENCE No DESCRIPT OF R FEE
HOUSE SEWER CONNECTING TOPUBLIC SEWER @ 58.00 TYPE OF CO N IN LENGTH FROM
SEPTIC TgNK,SEEPAGE PIT OR C PL. M L.TO P,L
PITS AND/OR DRAINFIELD @ 58.00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00
HOUSE SEWER CONNECTING TO P C NO. O
PRIVATE DISPOSAL SYSTEM @ S100 IMP NO JOB NO V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO ROAD PERMIT 110. IX
WORK TO HOUSE SEWER 5100
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT O
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO V
INDUSTRIAL N.I
WASTE APPROVAL
N
CHARGES Z
OWNERS PERMIT $ 1 2100 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 5 10C REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- yyy
V F
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DA INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS Dl�(„QF- 19_ NEW HOUSE SEWER
OWNER OR `/ CONNECT ADDITIONAL
OWNERS AGENBUILDING 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 pLTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTE
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 1 AM THE LjXpAL OWNER OF T ABOVE
DESCRIBED RESIDEN P . BACKFILL SEPTIC TANKS SPOO❑
SIGNATURE SEEP PITXS CESLS El
OF PERMIT.
VALIDATION ROE19RT A. WOOD
CK. M 0. GSH SUPERVISING MECHANICAL]ENGINEER
mm
61
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