HomeMy Public PortalAbout10649 DAINES DR_Sewer__ CEBGB 3 62
APPLICATION FOR PERMI
]6A6920
COUNTY OF COS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ` I'^I C n 4
JOHN A. LAMBIE. County Engineer ADDaess ILLI-L/
WILLIAM A. JENSEN. Supt of Building t
LOCALITY
NEAREST
FOR APPLIC N TO FILL DROSS Sr.
LEGAL �� �� ^ w
DESCRIPTION LOT NO OWNER / S /',(/� i
MAIL G� _ •CLI v ✓L
BLOCK TRACT ADDRESS /
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CIT r TEL. NO
USE OF
BUIL01NGS DISTRICT N CRO/ MAP PROCESSED BY
CONTRACTOR
l lr J24 4l t-I 1 _ I e .G PFJ
ADDRESS/ ( CONNECTION DATA
CITY TEL. NO. _1R7L�]S $T N O TH
J MANHOLE REFERENCE
REGISTRATION NO. / COUNTY -
ND. DESCRIPTION OF WORK JJJ FEENNE I LEN TH FR
HOUSE SEWER CONNECTING TO ,vim Y pE OF M.L,TG
P.L
PUBLIC SEWER ® $5.00 U[, P.C.NO. O
SEPTIC TANK.SEEPAGE PIT OR I JOB NO. V
PIT$AND/OR GRAINFIELD SI0,00 CO.IMP. NO.
33 7 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. C
PRIVATE DISPOSAL SYSTEM @ 53.00 J}J}Jy�I�I�
CONNECT ADDITIONAL BLDG.OR I AFFIDAVIT wqv([ [gs[x[xi RECORD.IN5TR.NO. DATE
WORK TO HOUSE SEWER a 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELO
EXTN.,CESSPOOL,ORYWELL.MANHOLE B 55.00 HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM CD S3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROV
OWNERS PERMIT $ z oo^
AUTHORIZATION TOTAL FEE C CONNECTION CXARGE 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 INSPECTOWS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BDILDING OR WORK
SEPTIC TANK.SEEP.PITISI
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER$. CESSPOOL ❑ DRYWELL ❑
IHEREBY 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
CALIFORNIA OR THAT I AM THE GAL OWN R OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE A OVE LESCR �E I/!C ROPERTY. ABANDON HOUSE SE WED
SIGNATURE 1_A BACKFILLSEPTIC TANKS ❑
OF PERMRT EE ( � BEEP,PIT I51 'TTG
CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER
Lji;o9 3 9 7— JPN11 1 0 D 7.00-
Of
CEBGB
78A662D 3-62 APPLICATION FOR PER IT
11
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1,L11(
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
IDNN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. IENSEN, Sup'1 o1 Building
NEAREST //`�
FOR APPLICANT TO FILL CROSS ST.
EGAL
DESCRIPTION LOT N OWNER
MAIL /A
BLOCK TRACT ADDRESS/ t•"
NO. OF BLDGS.
512E OF LOT NOW ON LOT T TEL. NO.
USE OF
T
BUILDINGS A. DI TRItCj/��O/. G'ROI MAP PG PROCESSED BY
CONTRACTOR I fly/ �Jx z— �C( O Y L K.� �J
ADDRESS ( G `V - V CONNECTION DATA
CITY A P� NII TEL. NO. �J i3/ ST N /) DEPTH / J'
TF-r /1 \� STATE gNHOLE REFERENCE(•'
REGISTRATION NO. � /❑ COUNTY.
No. DESCRIPTION OF W RK FE PE OF N oN m
HOUSE SEWER CONNECTING TO Y. B P.L. M.L.TO P. r
PUBLIC SEWER $5.00
SEPTIC TANK.5EEPAGE PIT OR 'J✓'f P.C.NO.
PITS AND/OR GRAINFIELD SIO.00 CO.I.E.NO. _3J / JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CO NNECT ADDITIO N AL BLDG.OR AFFIDAVIT MV [.•5[x FXI RECORD.INSTR.NO. DATE
W ORKTO ROU BE
SEWER S3.00 • M u
OVERFLOW SEEPAGE PIT.GRAINFIELD
EXTN..CESSPOOL,DRYWELL.MANH O LE® SS.00
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPO SYSTEM $3.00 STATE ENCROACHMENT
.� I PERMIT NO.
L 1 •
INDUSTRIAL
TIRAE
WA TRAPLR�O VA.L
OWNER'S PERMIT s �z t`tR
AUTHORIZATION TOTAL FEE CA CONNECTION CHARGE FEE
IHAVE 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 INSPECTOR5 SIGNATURE
SIGNED THIS DAY OF l9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT- CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION A ND/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 ❑ ORYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNT AND///STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE L L O NER OF. AN��•��-D/////IINTEND TO DISCONNECT PLUG AND
RESIDE IN. THE BOVE O BCRIB RE D 1 PR TY. ABANDON HOUSE G WER
SIGNATURE / BACKFILL SEPTIC TANKS ❑
OF PEgMITTEE L SEEP.PITIS) [ICESSPOOLS ❑
CVALIDATION ROBERT A. WOOD
cK M.O. CASH SUPERVISING MECHANICAL ENGINEER
L11G0 9 s a w �rtra l -1 1 1 D 25.00— M