HomeMy Public PortalAbout10643 DAINES DR_Sewer__ 76A64 10-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUDRESS
JOHN A. LAMBIE, County Engineer ADDRESS /1
WILLIAM A. JENSEN, Supt of Building l�—
LOCALITY
NEAREST
FO AP�PLIC NT TO FIL- J._ P RO55 BT'
LEGAL / (/- �' C
DESCRIPTION LOTN°. OWNER
1 G. MAIL
BLOCK TR4CT �C ADORES$
NO. OF BLOCS.
512E OF LOT NOW ON LOT CITY TEL. NO,
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
_ BK PGy
CONTRACTOR I D
ADDRESS �.. A ! CONNECTION DATA V
CITY TEL. NO. ❑ ATION DEPTH
REGISTRATION NO. Z_ ❑ COUNTY MANHOLE REFERENCE UPPER
COWI"R
NO. DESCRIPTION OF WORK FEE TYPE OF ONNEC N ' LENGTH FROM
HOUSE SEWER CONNECTING TO Y. ACU /� F.L M.L.TO P.L. Y
PUBLIC SEW ER @ $5.00 d
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR CO.H.P.NO. JOB NO. O
PITS AND/OR GRAINFIELD SIOOo U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a C
PRIVATE DISPOSAL SYSTEM n6 $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I 1,vHISIM[ RECORD.INSTR.NO. DATE F
WORK TO HOUSE SEWER ® $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIEL° W
E%TH.,CESSPOOL,DRYWELL.MAN H O LE 0 $5.00 w
ALT ER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING IA
SEWER OR DISPOSAL SYSTEM ® 53.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%ISTING °WELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS 'DAY OF 19_
OWNER OR NEW HOUSE SEWER A JL5[ uAJ
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING ORRWORK
WORK
SEPTIC TANK,SEEP,PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS gPPLICATIOA AND/OR DRAINFIEID
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
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 1 A THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO D SfftIBE RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE � BAC KEILL SEPTIC TANKS ❑
OF PERMITTEE [/"'D ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
M.O. GSH SUPERVISING MECHANICAL ENGINEER
CK..
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A10-63
76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIrvG
JOHN A. LAMBIE, County Engineer ADDHEss
WILLIAM A. JENSEN, Supt of Buildivg
LOCALITY
.7—
FOR APPLICANT TO FIL — ' CROSS ST. op
LEGAL } {
DESCRIPTION LO NO. .Jyl ( WNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SI2E OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS T DISTRICT NO. GROUPBK MAP PROCESSED BY
CONTRACTOR ^/ 9— L PG�
ADDRESS V V� CONNECTION DATA
X's
Z
CITY � ` -TEL. NO. L`� S TION .-I-STATE
RON NO.
I ❑ COUNTY MANN OLE REFERENCE UPPER
EG
NO. DISTRATIESCRIPTION OF WORK FEE TYPE OF CONNECTI LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CU 9 RL. M.L.TO P.L Y
PUBLIC SEWER 41) ISO. ` L d
SEPTIC TANK,SEEPAGE PIT OF - P.C.NO. O
PITS AND/OR GRAINFIELD @ S10.00 CO.IMP.NO. JOB NO. ///� V
HOUIVSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,7 0 Q:
PRATE DISPOSAL SYSTEM $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVITWAIVER ASEMEX RECORD.INSTR.NO. DATE r
WORK TO HOUSE SEWER @ S3OO V
OVERFLOW SEEPAGE PIT,ORAINFIELD W
EXTN_CESSPOOL,ORYWELL,M AN HOLE@ $IS 00 d
ALTER.REPAR ORABANDON .OUSE HWY. OR ST.WIDENING En
SEWER OR DISPOSAL SY ® 43.00 STATE ENCROACHMENT
Y PERM IT NO.
INDUSTRIAL A
WASTE APPROVAL
OWNERCONNECTION CHARGE FEE CHARGES
S PERMIT E —e
AUTIiORIZATION TOTAL FEE
V
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE NSPECTOR'SEIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECTADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP.FIT(S)
IMEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DpYWELL ❑
I HEREBY 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 ABO EE RIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_
SEEP,PIT(6) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CASH
7 9 7 7 ' JAN 28 1 1 D It"
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