HomeMy Public PortalAbout10550 - 10552 DAINES DR_Sewer__ Sa E-683 11 65
D APPLICATION FOR PERMIT105YO 5
S&E-8
DIVISION OF BUILDING AND SAFETY SEWER' EWAGE DISPOSAL
Department of County Engineer
County,of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUPT of BUILDING LOCALITY / GL
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO - OWNERMAIL
B
BLOCK TRACT (j 20 _ ADDRESS
NO OF BLDGS CITY TEL NO.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT O GROUP - I - MAP
BUILDINGS
BK PG
CONTRACTOR
J—� / CONNECTION DATA
ADDRESS
. ,.,/ STATION DEPTH
CITY TEL [ MANHOLE REFERENCE r UPPER
❑ STATE LOWER
REGISTRATION NO Y ❑ COUNTY ,I l
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO P OF CONNECTION _ LENGTH OM
PUBLIC SEWER @ $3 50 Y. CURB P L M L TO L
SEPTIC TANK,SEEPAGE PDT OR ��-- /&&&
_ PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD P C NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $ 2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR �y STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 it1 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL - -
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE, ,
OWNER'S PERMIT S 1 Oo
REIMBURSEMENT FEE r
AUTHORIZATION IDOTAL FEE Cp-t7
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR $SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THISDA OF 19 CONNECT ADDITIONAL �
OWNER OR � BUILDING OR WORK 24�✓
OWNERS AGENT_
_ SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ c
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A /OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND ST E OF ABANDON CT PLUGAHOUSE D
CALIF0 NIA OR THAT I ANI E LEGAL OWNU! OF TH ABOVE
DES ED�'E.SIDENTIAL PR Y BACKFILL SEPTIC TANKS El
SIG;ER
R/£/ � .� ' SEEP PIT(S) [I CESSPOOLS
0MITTE
JOHN A LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD. CHIEF PLBG INSPECTOR
CK 11 O
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