HomeMy Public PortalAbout10603 DAINES DR_Sewer__ DEPAICfMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER ODD ES G
`; .. ADDRESS �/1
FOR APPLICANT TO FILL IN LOCALITY
BUILDING / CROSS
ADDRESS / CROSS ST.
If
LOCALITY / _-u/ DISTRICT NO. SERIAL NO. PERMIT NO. L
CNEAREST
ROSS ST. / ✓(M A 1 / / S
OWNER
1I RECEIVED BY Ready fInspection DATE ISSUED
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MA.L USE 20NE OCCUPA CY MAP
ADDRESS jA(`/.r/(f^`//^J BK \SPG
CITY TELAO. '>'
CONTRACTOR Il � �7 / /5
CO.IMP.N0. J {"1
ADDRESS _ JOB NO.
CITY TELAG. TRUNK PERMIT NO. '
. / ❑ STATE _
REGISTRATION N0. s7 Z1 T �] COUNTY ROAD PERMIT NO.
LEGAL )^DESCRIPTION LOT N�. STATE ENCROACHMENT
(�' �f7 Y PERMIT NO.
BLOCK 2 TRACT —J.1 INDUSTRIAL
^^� / NO OF ILDGS. WASTE APPROVAL
SIZE OF LOT I D U (IIA GL NOW ON LOT ! - CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE - I
HOUSE SEWER CONNECTING TO �1 REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR I EXCEPTION RECORDED
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO' DATE IBY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
ANO/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR //
PITS AND/OR GRAINFIELD 2.00 STATIONIO d
DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 / MANHOLE REFEREffVEl �[/
/ UPPER (�' LOWER-
_ TYPE OF CONNECTION LENGTH FROM h �
OWNERS PERMIT f 1 00 B- P.L. M.L.TO P.L. �J
AUTHORIZATION I TOTAL FEE
1HAVE THIS DATE CONTRACTED WITH THE HERE14 NAMEDI
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIG NATURE DATE
DWELLING TO THE PLLBLIC SEWIM
._ ' �g
SIGNED THISAY OF.... ._.___-_.� NEW HOUSE SEWER
OWNER OR i�L� . CONNECT ADDITIONAL
OWNERB AGENT... ..... .. .. ..._........ ...... _ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT($)
ADDRESS.._...r... ...._... _.._. . . _ .......... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL 0
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 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REqVIRED BY LOS ANGEL S COU TV DISCONNECT PLUG AND
AND STATE OF CALIFOflN OR HATE GAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE 8 P TV. BACKFILL SEPTIC TANKS Ej
SIGNATURE SEEP.PIT(S)Q CESSPOOLSOF PERMITTEE .. ...... . _.._.-_.._._
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