HomeMy Public PortalAbout10708 DAINES DR_Sewer__ CA43420 _,z` APPLICATION FOR PERMIT
E80S D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE. County Engineer ADDHEss
Atl
WILLIAM A. JENSEN, Supt of Building
11 LOCALITY
N EAfl EST
FOR APPLICANT TO FILL IN R05S ST. '
LEGAL
DESCRIPTION LOT NO. OWNE_R-
MAIU�
BLOCK TRACT ADDRE
SrzE OF LOT
NO NOW ON LOT I CITY TEL. NO.
USE OF
BUILDINGS D_S / DISTRICT NO. GROUP[, MAP PROCESSESY
CONTRACTOR PRO
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ADDRESS. ° CONNECTION DATA
STATION DEPTH
CITY ��i/(P m �. TEL NO. A t
U ❑ ST TEMANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER d
NO. J DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM O
H°USE SEWER CONNECTING TO Y. CURB P.L, M.L.TO P.L. V
PUBLIC SEWER @ $5.00 P,C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD C 510.00 CO.IMP.ND. JOB NO, rO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (J
PRIVATE DISPOSAL SYSTEM @ S. lyi
/ CONNECT ADDITIONAL BLDG.OR ^J �'/J AFFIDAVIT uv ssn[ RECORD,IN5TR,NO. DATE a
WORKTO HOUSE EEWE R @ 53.00 �1
OVERFLOW SEEPAGE PIT.°RAINFIELD L
E%TN_CESSPOOL,ORYW ELLMANHOLE $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.°R ST.WIDENING
SEWER OR DISPOSAL SYSTEM 33,00 STATE ENCROACHMENT
PERMIT No
`� 7
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 5 z l ^0,fi�0CHARGES
AUTHORIZATION TOTAL FEE r, CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX15TTNG DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR5 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT
CONNECT AppITIONAL C [['/rY/
ADDRESS BUILDING OR WORK k
SEPTIC TANK.SEEP.PIT(5) I / <�
I HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLICATION AN°/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 ANO/OR ALTER, REPAIR.SEWER OR r
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWNER OF AND INTEND TO O15CO19NECT PLUG AN.
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIA P PERTY. . ABANDON HOUSE SEWER
SIGNATURE BACK FILL SEPTIC TANKS ❑
OF PERMI E ` SEEP.PIT(5) El CESSPOOLS ❑
/ VALIDATION ROBERT A. WOOD
CASH SUPERVISING MECHANICAL ENGINEER
< r�o7 0 7 9 APR 20 1 0 D 5.00