HomeMy Public PortalAbout10640 DAINES DR_Sewer__ 76AS420 APPLICATION FOR PERMIT GGG
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DIVISION OF BUILDING AND, SAFETY SEWER—SEWAGE D ISPOSAL
Department of County Engineer -- -'
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS r�
® CASSATT D. GRIFFIN. SUa'TOF BUILDING LOCALITY
_ FOR APPLICANT TO FILL IN caoss sT.
LEGAL „�OP ,( zy OWNER
DESCRIPTION LOT N0. G
MAIL
BLOCK TRACT �/ �/, ADDRESS
T NO. OF RLDGS. - — q
SIZE OF LOT NOW ON LOT CITY fs.-a».-L TEL. NO. /.
USE OF
BUILDINGS G Q.�LL DISTRICT NO. GROUP MAP
S
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
/ Et f�
STATION 0 L DEPTH
CITY l TEL. N0. MANHOLE REFERENCE ' D ” PP
X STATE / LOWER
' REGISTRATION NO. j - .5E3 COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ..yl TYPE OF CONNECT] LENGTH ROM
PU BLIC SEWER @ $3.50
J (� Y. CURB P. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @- $3.00 �]
OVERFLOW SEEPAGE PIT. DRAINFIELD !33 / JOB NO.
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $2.00 CO. IMP. NO. 1
No
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
F WORK TO HOUSE SEWER @ S 1.00 PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE.FEE
OWNER'S PERMIT S 1 0o
AUTHORIZATION TOTAL FEE REIMBURSEMENT'FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'SSIGNATURE /
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING D /� �O
TO THE PUBLIC S/EEl/y.��t NEW HOUSE SEWER
SIGNED THIS:I LDAYy�p 19. -CONN
OWNER OR ,/n/JnL� . rP 6 a _. (L /, BUILDING OR WORK
OWNERS AGENT �� !/� �i/11. -YS/6-✓ SEPTIC TANK,SEEP,PITIS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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
I HEREBY CERTIFY THAT 1 AM PROPERLY - ISTERED AND/OR AND
LICENSED AS REQUIRED BY LOS ANGELES LINTY AND STATE OF DISCONNECT ABANDON HO PLUG PLUGUSE D
CALIFORNIA OR THAT I AM THS GA OWNER OF THE ABOVE _
ER
DESCRIBED RESIDENT] ROPER Y. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PITS) ❑ CESSPOOLS❑
OF PERMITTEE. L'1 G' ( 7 �))I�
JOHN A. LAMBIE, - UNTY ENGINEER 1 ALIDATIOO /IAI/'1 ROBERT A. WOOD,-CHIEF PLSG. INSPECTOR
K. Y.0. /�cnsx/ -
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