HomeMy Public PortalAbout10628 DAINES DR_Sewer__ eE:
446�INSER
CEBoe APPLICATION FOR PERMIT-
. �exsazD COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION euILDING //'`'
AOORE55 - L'
IOHN A. LAMBIE, County Engiaees -
WILLIAM A. JENSEN, Supt of Building LOCALITY -
- NEAREST
AL
7jDEZSCRIPT1ONJ
PPL))ICANVTJ TO FoILL IN caoss sT.
NO, b(�' (dpC/ 'OWNERCT 61i MAIL
ADDRESS
NO.OF BLDGS.NOW ON LOT .CITY TEL. NO.
DISTRICT NO. GROUPI MAP PGPROCESSED BY
UT)
- BK PG
CONTRACTOR 1
I ADDRESS - CONNECTION DATA
CIT EL N0. >OL�jl STATION 3- 0 , O DEPTH
qrf STATE 'MAN HOLE REFERENCE UP
REGISTRATION NO. " 6 Ti ! y COUNTY �� LOWER
NO. DESCRIPTION.OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC.TANK, SEEPAGE PIT OR Y. CURB - P.L. M.L.TO P.L. o�V
?ITS.AND/OR
SEEOPGEAINFIELO @ $3.00 v
OVEA . DRAINFIELD
EXTN..RFLOW SEEPCESSPOOL DNYWEPITLL @ 82.00
HOUSE SEWER CONNECTING TOP.C.NO•
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO. M
WORK TO HOUSE SEWER @ $1.00 U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
EWER OR DISPOSAL SYSTEM @ $1.00 'PERMIT NO. 0
1,7
'INDUSTRIAL U
WASTE APPROVAL W
CHARGES o
OWNER'S PERMIr $ Q 00 CONNECTION CHARGE FEE rl
AUTHORIZATION TOTAL FEE G O REIMBURSEMENT FEE
1 HAVE AT,THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING. DWELLING APPROVALS _OATS IRSPECTOMS SIGNATURE
TO THE PUBLIC SEWER. �
SIGNED THIS DAY OF t9_ NEW HOUSE SEWER i o!i' _ :'/.
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - - - -AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL I] DRYWELL ❑
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, ABANDOM'HOUSEBEWER '
CALIFORNIA OR THAT I AM T LEGAL OWNER OF THE ABOVE
DESCRIBED RESIOEN PROPE `
BACKFILL SEPTIC TANKS ❑DESCRIBSIGNATED
SEEP.PIT IS) Cl CESSPOOLS ❑..
OF PERMITTE
®� VALIDATION V ROBERT A. WOOD
CIL
M.0. .CASH SUPERVISING MECHANICAL ENGINEER -
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'CE8
08 6.60
APPLICATION FOR PERMIT
]5Ae azD o COUNTY OF LOS ANGUES1
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL.
BUILDING AND SAFETY DIVISION suaomc -
ADORES$ / iL�
]OHN A. LJENSE, , OuntY En uildi �c
WILLIAM A. (ENBEN, Supt of Building LOCALITY
.NEAREST -
FOR APPT. A{'7NT T-JO� /FILL IN�J CROSS ST.
LE
D SCRIGP7 LOT NO.� 749 CO)� /CS OWNER
TRACT74 g - .MAIL
_ J f7 ADDRESS
NO.OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF 'DISTRICT N0. Ge {e I _ Y
BUILDINGS a-ti�. - �K MAP P OCESSED BPG J/ I
CONTRACTOR
ADORE I(e CONNECTION DATA
CITY B TEL.NO. STATIO f DEPTH
[STATE MANHOLE REFERENCE -
REGISTRATION N0. 10 2. ❑ COUNTY LOWER
' NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER CO $3.00 -� TYPE OF CONNECTION LENGTH FROM 'J
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. °C -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD aK
EXTN.. CESSPOOL. DRYWELL @ $2.00 P.C.NO.
HOUSE SEWER CONNECTING TO CO.IMP. NO, ,_7j JOB.NO.
PRIVATE DISPOSAL SYSTEM @ $I.00 M
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROE
WORK N0. 9 U
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0. O
M
INDUSTRIAL. - U
_ WASTE APPROVAL a
CHARGES
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE'
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR'TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER - - -
OWNER A �� CONNECT ADDITIONAL
OWNERS AGENT - BUILDICONNECT
OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i HAVE.READ THIS APPLICATION - - - --
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING_ ALTER,.REPAI R.SEWER OR
PLUMBING AND SEWERS. -
i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNEECTCT PLUG AND
CALIFORNIA OR THAT AM ELEGAL OWNB@ OFTHE ABOVE ABANDON HOUSE SEWER
DESCRIBED BESIDE?T L P 0 T ` L BACKFILSEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS ❑ _OF PERMITT E
®. VALIDATION ROBERT A. WOOD
- °X. M.O. usx S PERVISING MECHANICAL ENGINEER .
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