HomeMy Public PortalAbout10608 DAINES DR_Sewer__ J . APPLICATION FOR PERMIT
B&t66DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer ®'
County of Los Angeles BUILDING /e./d57 p p I N C S
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS ssww 57
® CASSATTD. GRIFFIN. SUP•TOFBUILDING LOCALITY Taof IV,a Cj
FOR APPLICANT TO /Flu IN / cROSSS ST.. PAL I!-_
DESCRIPTION LOT NO. / 7 S/'7-J / /-D / OWNER (f,'RdaNl /(L 2
/ Q 0 MAIL
BLOCK TRACT (! / ADDRESS [
NO. OF BLCITY M P,CC l K�TEL. NO.
SIZE OF LOT NOW ON LOTT
USE OF
BUILDINGS /� DISTRICT NO. GROUP 7/�I �/ � � � BK MAP ..
PG
CONTRACTOR G S
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. N0. MANHOLE REFERENCE UPPER
El STATE LOWER
REGISTRATION N0. Ll COUNTY , / Q
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CON ECTION LENGTH FROM
Y. CURBNP.L. M.L.TO P.L.
.P UBLIC SEWER @ S3.50
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ S 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 STATE ENCROACHMENT
WORK TO HOUSE SEWER .00 PERMIT NO.
.•rro o .•���gBANDON/f6tl9E ,Y INDUSTRIAL
SEWER GR-BiFBGGrFk SYSTEM @ $1.00 V WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S P RMIT S I 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
O f7
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ ORYWELL❑
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 r.!• �.//;:2 :?'L i/
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF gBANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TIAL PRO ERTY, q �, BACKFILL SEPTIC TANKS❑
SIGNATURE I SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTE / ��•
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK. m,O, p5N
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