HomeMy Public PortalAbout10540 DAINES DR_Sewer__ IDEPARTM3MVT OF COUNTY ENGINEER � '-: ''SEWER—SE�/AGE DISPOSAL
DIVISION OF BUILDING AND SAFETY � PERMIT APPLICATION 1 0 9 7 1
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING // n
ADDRESS
LOCALITY
FOR APPLI ANT,{ TO FILL IN
BUILDING/ ,r/ J� t NEAREST
ADDRESS /J CCC i/JI L/ / CROSS ST.
LOCALITY � � ( DISTRICT NO. w SEMIAL NO. PERMIT NO.
NEAREST /� '3` A / Q
GROSS ST LN
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4 !RECEIVED BY Ready for InsOeotlon DATE ISSUED
OWNER)k4� rr/�� ! ,`\ Jf�� /
MAIL ] `_ j �/ USE ZONE OCCUPANCY BK MAP PO
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CITY I TEL.NO.
CONTRACTOR '
.alifornia Sewer Const Co 1 CO.IMP.NO. yC 9
ADDRESS 1317 Collegroye Ave. JOB.NO.
CITY Montebello 1 TEL.NOUNion 1-5048 TRUNK PERMIT NO.
REGISTRATION NO 1044/45 StRI NTY+
ROAD PERMIT NO.
LEGALSTATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 7,j x Z NOWO OF BLDGS. ` /
/ NOW ON LOT 1 _CHARGESUSE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 0 RECEIPT NO. DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG.OR /EXCEPTION RECORDED
WORK TO HOUSE SEWER -" 1 00
ALTER OR REPAIR EXISTING / NO. 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 w r
PITS AND/OR DRAINFIELD 200 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 / MANHOLE REFERENCE
p •�S W LOWER
TYPE OF CONNECTIO LENGTH FROM �—
OWNERS PERMIT $ I 00 CHAS cL M L TOP L
AUTHORIZATION I TOTAL FEE I �
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN N)IMEDe
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXIS?MG APPROVALS INSPECTOR'S SIGNATURE .DATE
DWELLING TO THE PUaLIC SEWER
SIGNED THIS `30__ ___DAY OF_-___ .. ._ _______..19.33 NEW HOUSE SEWER
OWNER OR ` e -- CONNECT ADDITIONAL
OWNERS AGENT _. BUILDING OR WORK
��
�� SEPTIC TANK,SEEP.PIT(S)
ADDRESS ov AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI-I CESSPOOL E] DRYWELL E]
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 HFREBY CERTIFY THAT I AMR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
PROPERLY REGISTERED DISCONNECT
AND/OABANDON HOUSE-SEWER PLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURESEEP PIT(S)El CESSPOOLS
OF PERMITTEEO—),',j_Y ....__ _.._
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