HomeMy Public PortalAbout10820-10822 DAINES DR_Sewer__ _°
1E111r $R APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES�' SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU'LDIMG e
ADDRESS
])OHN A. LAMBIE. County. Engineer
CASSATY D. GRIFFIN. Sup t of Building LOCALITYARE
'
FOR APPLICANT TO FILL IN
CROSS ST. .�
LEGALOWNER
DESCRIPTION LOT N0. —�
BLOCK TRACT MAIL --'
ADDRESS
N0.OF OLD S.
/SIZE OF LOT NOW ON LOT CITY Et. NO.
USE OF p DISTRICT N0. GROU
MAP I P OCESSED
BUILDINGS rY / BK PG
CONTRACTOR Y
ADDRESS — yl/ CONNECTION DATA • °
CITY TEL. 7df.5! 1 STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY WE
NO. DESCRI ION OF WORK FEE r
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 VV TYPE OF TION LENGTH FROM tomI
SEPTIC TANK,SEEPAGE PIT OR Y. CU P.L. M.L.TO P.L. �.j
PITS AND/OR DRAINFIELD @ $3.00 t
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ S1.00 ,�..^^ CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR W TRUNK PERMIT NO. R T NO.
WORK TO HOUSE SEWER @ $1.00
ALTER.
DISPOSAL SYSTEM HOUSE @ $I OO STATE
PERMIT NO.
IN IAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 660 REIMBURSEMENT FEE
NAMED CON-
TRACTOR TO CIONNECT T EO NTRACT ABOVE DESCRIBED EXIISTTHE IING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS—DY OF 19 NEW HOUSE SEWER /Z'•
OWNER OR �7� t- ,/F��,.� CONNECT ADDITIONAL _
OWNERS AGENT��f /T �� tlT^^� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY- ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBINGANDSEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR AND
DISCONNECT PLUG
LICENSED AS REQUIRED BY LOS ANGELES-COUNTY AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L ROP RTY. BACKFILL SEPTIC TANKS ❑
/� SEEP.PIT(S) ❑ CESSPOOLS ❑ '
SIGNATURE /t:
OF PERMITTE v�
®" VALIDATION .ROBERT A. WOOD
l/=Lr'iJJ M.°. CASH SUPERVISING MECHANICAL ENGINEER
�o88572-,- DEC 281. 0 A 6 0