HomeMy Public PortalAbout10641 DAINES DR_Sewer__ CE809 I0-E3 '' .�` APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O r
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, S9P.t of Building
LOCALITY
- NEAREST
FOR APPLICANT TO FILL INJ' CRO55 ST.
LEGAL t
DEIce—
SCRIPTION LOT NO. OWNER
MAIL
BLOCK TRAC �j� ADDRESS
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT CITY TEL, NO,
USE OF
BUILDINGS DISTRICT NO. GROUPK MAP 7CE5SEO BY
CONTRACTOR
ADDRESS CONNECTION DATA
CITY EL. NO. I� J(J %� TATION �J 7<AA DEPTH
❑ STATE MANHOLE REFERENCE JJ UPPER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNE ON LENGTH FROM q
HOUSE SEWER CONNECTING TO Y. R P.L. M.L.TO P.L.
PUBLIC SEWER a 55.00 v. }
P.C.NO. D
SEPTICTANK.SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD 1I0.00 CO.IMP. NO. .108 NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. D v
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAlvq 111141XT RECORD.INSTR.NO. GATE 0
WORK TO HOUSE SEWER ® s3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
E%TN..CESSPOOL,DRYWEL L,MANHOLE® Ss.00 W
ALTER.REPAIR OR ABANDON HOUSEHWY. OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM 113.00 STATE ENCROACHMENT _Z
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL _
OWNERS FERMIS s z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONN ECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTo CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK V
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT I61
ANO/OR GRAINFIELD
STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A C ED ESIDENTIRL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE �. /f �hJ _ BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP.PITISI ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
Ln�o 7 9 7 4 LG JA.N 2 8 1 0 D 7.0 0- <
1 i f•
` 42 f°-63
)6A6AB4APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ' BDILDING
JOHN A. LAMBIE, C.unty Engineer ADDRESS
WILLIAM A. rEN$EN. Bup't of Building
OCALITY
-- - - NEAREST
FOOT APPLICA T TO FILL N�- .Za CR°55 $T.
LEGAL
el
DESCRIPTION LOT NO. OWNER
BLOCK TRACT /lC�Qi�pjt. �- ADDRESS
,NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO,
[ADDRESS
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
X// BK PG
CTOR
. i- - CONNECTION DATA
CITY TEL. NO. ATION DEPTH 'T
r ❑ STATE ' C UPPER
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE
NO. DESCRIPTION OF WOR FEE TYPE OF CONN_EC O / LENGTH FROM
HOUSE SEWER CONNECTING TO Y. S ,�P.l�. M.L.TO P.L. }�
PUBLIC SEWER @ S5.00
SEPTIC TANK,$EE PAGE PIT OR P.C.NO. O
CO.IMP. NO. JOB NO.
PITS ANp/OR DRgINFIELD @ YI0.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. -
PRIVATE DISPOSAL SYSTEM $3.00 0
1�
CONNECT ADDITIONAL B L.G.OR AFFIDAVIT 41Y 1514[ RECORD. INSTR.NO. DATE VI...
WORK TO HOUSE SEWER 53.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL.MANHOLE SS.00 d
ALTER, REPAIR OR ASARCOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL YSTB @ S3O. STATE ENCROACHMENT
PERMIT NO.
- A
I
INDUSTRL
WASTE USTRAPPROVAL
OWNER'S PEAMIT 3
AUTHORIZATION TOTAL FEE I
CONNECTION CHARGE FEE
'I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED C.N. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY/pF 19_
OWNER OR /A/ / NEW HOUSE SEWER
OWNERS AGENT- CONNECT ADDITIONAL
'pDflE55 BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTICTA NK,S EEE,PIT(S)
ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE ICOMPLY
WITH ALL COUNTY ORDINARIES
CORRECT AND AGREE S AND STATE LAWS REGULATING Ll
PLUMBING AND SEWERS. CESSPOOL ❑ DflYW EIL ❑ t
HEREBY CERTIFY THAT I AM PROPERLY REGISTEREO AND/OR A LTER. REPAI P.SEWER OR `
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. ANO INTEND TODISCONNECT PLUG ANO
RESIDE IN, THEABOVE p C E RE55y��OENTIAL PRiO�PER
/� ABANDON HOUSE SEW ER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANK. ❑
SEP.PIT 151 ❑ CESSPOOLS ❑
/ 1VA IDATION ROBERT� WOOD�v/ SUPERVISING MECHANICAL ENGINEER
CK. M. O. CASH
(; � 7 9 7 5—� JAN 2 8 1 1 D 2 5.00-