HomeMy Public PortalAbout10617 DAINES DR_Sewer__ CEBO76A64B 1 tJ-53 APPLICATION FOR PERMIT '
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /.
JOHN A. LAMBLE. County Engineer ADDNEss ` IPA
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT IN `ROSS ST.
LEGAL ®
DESCRIPTION LOT NO. /C� OWNER
MAIL
BLOCK TRACT ADDRESS
NO, OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP P O ESSED BY
BUILDINGS
_ J// (//�' BK PG
CONTRACTOR S/ /l '
ADORES$
J c/ Y < CONNECTION DATA
- - �3 STMION ✓ DEPTH _•Q
CITY TEL. NO. Y
R STATE ��y UPPER
REGISTRATION NO. Lf COUNTY MANM OLE REFERENCE
NO. 1 DESCRIPTION OF WORK FEE TYPE OFCONNEC LENGTH FROM
HOUSE'SEWER CONNECTING TO Y. �+ CU B P.L. M.L.TO P.L. �[
PUBLIC SEWER S5.00
SEPTIC TANK,SEEPAGE PIT ORP.C.NO. O
CO,IMP. NO. I JOB NO.
PITS ANO/OR DRAINFIELD CSA f10.00 U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT 1'
PRIV ATE DISPOSAL SYSTEM ® $3.00 /1
CONN ECT ADDITIONAL SLOG,OR AFFIDAVIT I WAIY 55[A[ RECOR D.INSTR.If.. DATE ZIV
WORK TO HOUSE SEWER ® S3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD W
E%TN_C ESSPOOL.ORYWELL.MANHOLE $5.00 n
ALTER,REPAIR OR ABANDON HOUSE Y.OR BT.WIp ) '
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROA\H LENT 4
PERMIT NO.
INDUSTRUL
WASTE APPROVAL
CHARGES
OWNER$ PERMIT s 21 00
AUTHORIZATION TOTAL FEE 1, CONNECTION CHARGE FEE
'1 HAVE AT-THIS DATE.A CONTRACT WITH THE HEREIN. NAMED CON- REIMSV RSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTO 'S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING _
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL Cl
IHEREBY CERTIFY THAT 1 AM .PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM - -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV&DESCRIBEP RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE /` BACKFILL SEPTIC TANKS ❑
OF PERMITTEE liO&Awl ❑
EXP.PIT IS) ❑ CESSPOOLS
VALIDATION r A. wo0o
cK. M.0. CASH SUPERVISISINGNG MECHANICAL ENGINEER
_
^1008 1 2 3G FEB 1 1 0 0 7.00-
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`E808 DI°-B3
A64APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F�DLDING
g;
JOHN A. LAMBIE, County Engineer RESS
WILLIAM A. IENSEN, Supt of Building t ALITYRESTFOR APPLICANT TO Flkf 1 SS 5T.LEGAL DESCRIPTION LOT NO. / L1Z
BLOCK TRACT - ADDRESS
NO. OF SLOGS.
512E OF LOT NOW ON LOT CITY TEL. NO.
USE OF. E
DISTRICT NO. GROUP MAP P SSED BY
BUILDINGS /
BK PGy
CONTRACTOR � r (+� y
ADDRESS ! 'CONNECTION DATA
CITY TEL. NO.,07C/ 5 ATION DEPTH �/I
v11S TAE (/ UPPER
S
REGISTRATION NO. / B COUNTY MANHOLE REFERENCE t , L01MB1!•
NO. DESCRIPT ON OF WORK FEE TYPE OF CONNECT • LENGTH FROM
HOUSE SEWER CONNECTING TO
Y. � CU P.L. M.L.TO P.L.
PUBLIC SEWER @ se.00N0'
CO.IMP. NO. , JOB
}
SEPTIC TANK,SEEPAGE PIT OR i
Joe NO. O
PITS AND/OR GRAINFIELD S10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT /
PRIVATE DISPOSAL SYSTEM 33.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT gSMlui RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER ® $3.00 ' r
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN..CESSPOOL,DRYWELL.MAN NO
LES 35.00 W
ALTER.REPAIR OR AOAND OUSE HWY,OR 5 O NIN ,LL/ �/) Q• c7 Z
SE
W ER OR DISPO SAL YS / ® 53,00 STATE ENCROACHMENT +v/ V
/ PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
0
OWNER'S PERMIT s CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION rdTAL FEE r0
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C.N. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS O F 19_
OWNER OR � NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OROR WORK
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(S) �• �L.LSr
AN
DRAINFIELD L M`rJ
AND STATE THAT THE�ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ n /'
HEREBY CERTIFY THAT'I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE 015POSAL SYSTEM f
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND {
RESIDE IN. THE ABO ESCRIBED RESIDENTIAL PR*;;B .
!!//JJJJ ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ V
OF PERMITTEE ❑
SEEP,PIT(S) ❑ CESSPOOLS
^`VALIDATION ROBERT A. WOOD
EUK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
Lj'C08 ,1^2 44` FEB 1 1 1 D 25.00- `v
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