HomeMy Public PortalAbout10647 DAINES DR_Sewer__ T&
CES083.62 APPLICATION FOR PERMI /y/E11
T6p642D 11
COUNTY OF LOS ANGELES SEWER—SEWAGE DIS SAL 11Y,1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOAN A. LAMBIE. County Engineer ADDRESS f_q_l_a4J/� Q
WILLIAM A. JENSEN. Sup't of Building -b/
LOCALITY �-{'
NEAREST
FOR APPLICANT TO FILL CROSS ST.
LEGAL G '/�
DESCRIPTION LOT NO. OWNER C L r +
✓ Ifflf
MAIL /
BLOCK TRACT ADDRESS/ L11
V NO. OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT GROV MAP PROCESSED BY
_ BK PG_
/�/ 1y-/_/ / a�/�/I
CONTRACTOR _6w my _ A/• JI 0 1
ADDREssG 4/ CONNECTION DATA
T•E'L[ N'O. � ION TSj/ J
�•/ 4 f/{ 1—// �/ STATE MANHOLE REFERENCE
REGISTRATION NO. `/ COUNTY 6
NO. DESCRIPTION OF�KFEE TYP F NECTION LE GTH FR /
HOUSE SEWER CONNECTING TO RB P.L. M.L.TO P.L.
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR `7
PITS AND/OR GRAINFIELD @ $10.00 CO.IMP.NO. �J JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. K
PRIVATE DISPOSAL SYSTEM 33.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVITwlnu EAS[R[x RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 33.00
OVERFLOW SEEPAGE PIT.GRAINFIELDq
EXTH..CESSPOOL.DRYWELL.MANHOLE xv $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR sT.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
STE A P
Fg
OWNERS PERMIT s z oo G S
AUTHORIZATION TOTAL FEE / CONNECTION CHARGEFEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'551GN TVRE
SIGNED THIS DAY OF 19_ �♦ 'j �
OWNER OR NEW HOUSE SEWER I/b1)3
OWNERS AGENT_ CONNECT ADDITIONAL F �
BUILDING OR WORK [
ADDRESS
SEPTIC TANK,SEEP.PIT(S)
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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 ❑
1HEREBY 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 THE L G' OO INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE BOV ESCRI SI IAL P PERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT IS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
LAGo 9 ' 9 5G, JAPd l 1 1 O D 7.0 0—
CEBGB APPLICATION FOR PERMIT
Tsgeaz0
COUNTY OF LOU ANGELES DISPOSAL u
DEPARTMENT
T OF COUNTY ENGINEER SEWER-SEWAGE
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE. County Enginoor "Go Ess )7 _
WILLIAM A. JENSEN. SuP't of Building
LOCALITY //"�.
NEAREST
FOR APPLICANT TO FII `ROSS ST.
LEGAL
DCRIPTION LOIN OWNER
ES /
MAIL /
BLOCK TRACT ADDRESS'lem. `/
NO. OF SLOGS. �' T L_
512E OF LOT NOW ON LOT CIT TEL. NO.
USE OF
BUILDINGS DISTRICT O. G OV MPP PROCESSED BY
TOR /J`!`/7j//�r' � / U B
CONTRACTOR
ADDRESSCONNECTION DATA
�/J // 5 ON DEPTX
CITY /'� /AL�ySK_ TEL, NO. C•
-Y/-/- •-+l �/^�/`/ STATE MANHOLE REFERENCE )) VPPE
REGISTRATION NO.
NO. DESCRIPTION OF WORK
��"•••////FEEYpEO O 310 LEI THF M ✓�
HOUSE SEWER CONNECTING TO Y, P.L. M.L.TO P.
PU BLIC SEWER 55.00 O
SEPTIC TANK,SEEPAGE PIT OR P.C,NO. V
PITS AND/OR GRAINFIELD n8' 510.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO. O
NAL
PRIVATE DISPOSALTEM 59.00
CONNECT ADDITIONAL SLOG.OR AFFIDAVIT •IY XS[M[Xt RECORD. INSTR.NO. DATE
W ORK TO ROUSE SEW ER a 53.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
E%TN„CESSPOOL.DRYWELL,MANXOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE OR ST,WIDENING
SEWEROR OISP F
SAL SYSTEM 53.00 STATE ENCROACHMENT
_/_
PERMIT NO.
INDUSTRIAL
W TE wPPROV L
OWNERS PERMIT S
CONNECTION CHAflGE FEE
[AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF '19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SELD T(S)
AND STATE THAT THE ABOVE 15 CORRECT AND
AGPEE TO COMPLY ANDIOR GRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL [I
' HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA LI FORMA OR THAT THE L qL OWNER OF, A INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A OVE SCRIB R E TI Lip ERTY. ABANDON HOUSE SEWER
SIGNATURE '4 BACKFILL BEPTIC TANKS ❑
OF PEflMITTE SEEP,FIT(S) ❑ CESSPOOLS E]VALIDATION ROBERT A. WOOD
CK. M. CASH
SUPERVISING MECHANICAL ENGINEER
O.
L�L.O9396-� JAN 1111 D 25.00 a'