HomeMy Public PortalAbout10614 DAINES DR_Sewer__ APPLICATION.{OPPLICATION FOR E-.FG3 11.55 OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of LOS Angeles BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS �' sY ✓�C/
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY�F% �`� L,TGA
FOR APPLICANT TO FILIL�IN OR AREsi.
LEGAL
DE CR PTION LOT 110#700
/Y �Q�J OWNER
BLOCK TRACT/
MAIL
�T'IADDRESS
O.OF BLDGS. CITY TEL. NO.
SIZE OF LOT /`�C rJ NOW ON LOT /
USE OF
BUILDINGS " J
DISTRICT NO GROUP B MAP
BK PG
CONTRACTO R-
CONNECTION DATA/
.1 / / ��A i STATION �� DEPTH / Q
CITY /y C Irl TEL. NO. '� s�+ MANHOLE REFERENCE PPER
REGISTRATION NO. � 3r. COUNTY / J�2T
NO. DESCRIPTION OF WORK FEE'
-- Y TYPE OF CON CTION LENGTH FROM�
HOUSE SEWER CONNECTING TO73 ,Vig?w
l PUBLIC SEWER @ $3.50
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 ) ^�
OVERFLOW SEEPAGE PIT, GRAINFIELD CO. IMP. N0./ ,J POB NO.
O.
EXTN..CESSPOOL,ORYWELL,MANHOLE Q $2.00
HOUSE SEWER CONNECTING TO If
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.N /C
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $L00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
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 D Y OF 19_ CONNECT ADDITIONAL
OWNER OR � BUILDING OR WORK
OWNERS AGEN
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBYL NOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
p3 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS ANGELES TY STATE OF
CALIFORNIA DR THAT T E LEGAL W R THE ABOVE ABANDON HO USESEWER
DESCRIBED RESIDENT, PROPE Y. / BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP. PITISI ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. OUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CN, M.0.
L,�[,O' 2 3 0 2S:; SEP 16 4 4-50 9
a
s&K.a09 11.55 APPLICATION FOR PERMIT SI
II,
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 2IIS
Department of County Engineer -
County of LOS Angeles BUILDING `
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN. SUPT Op BU'LDWG LOCALITY e / ,.
NEAREST �t�/ /
FOR�APPLICANT/T,O FILA IN l ceass sr.L_ ave
LEGAL A,7 p � ♦ OWNER /
DESCRIPTION LOT NO. L J" /7 ,MAIL
MAIL
BLOCK TRACT
�4 9ADDRESS
d /O&i/ ai 'Z)r v e
NO. OF SIZE OF LOT NOW ON LOTS CITY y Q TEL. N0. ^
USE OF DISTRICT NO. GROUP MAP
BUIL
DINGS
J zK
PG�
CONTRACTOR � C/Y�
CONNECTION DATA
' ADDRESS
STATION DEPTH
CITY TEL. N0. MANHOLE REFERENCE UPPER
❑ STATE LOWER
REGISTRATION NO, ❑ COUNTY
No. DESCRIPTION OF WORK FEE �L --ems• �� O Z
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER , @ $3.50 Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT. DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $LOO TRUNK PERMIT NO. ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG.OR .J. �^T STATE ENCROACHMENT I/HJT
WORK TO HOUSE SEWER @ $1.00 W PERMIT NO. Ay"
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL .v
'CHARGES �/ ♦y /-
CONNECTION CHARGE FEE �' V
_ OWNER'S PERMIT $ 1 DO A
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 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, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION , CESSPOOL❑ DRYWELL❑
ANp 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISC ON HO PLUGAUSE D
CALIFORNIA OR THAT I AM THE LEAGAL OWNER OF THE ABOVE
DESCRIBED RESID TI PERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. NT(5) ❑ CESSPOOLS CI
OF PERMITTEE -
JOHN A. L IE. COUNTY ENGINEER VALIDATION ROBERT A.WOOD. CHIEF PLBG. INSPECTOR
[K.
LAC04573u; SEP 8 1 A 2.00 �•