HomeMy Public PortalAbout10918 DAINES DR_Sewer__ - D
S&E6APPLICATION FOR PERMIT
BDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer -
County of Los Angeles rA
.JOHN A. LAMBIE. COUNTY ENGINEER® CASSATT D. GRIFFIN, SUPT OF BD]LDlrvc OCALITY
FOR APPLICANT TOLEGAL FILL INy /� ceo"Ss sT.
DESCRIPTTII�ON LOT N0. �l /y�0 0.6;' G i7VOF OWNER ` y
AIL
BLOCK }t Z TRACT". / D J� q —ADDRESS / Gi _
1/�
NO OF BLDGS. CITY
'SIZE OF LOT NOW ON LOT
USE DI
BUILDINGS STRICT NO. GROUP MAP
PG
' CONTRALTO
CONNECTION DATA
ADDRESS /1 ,
OV STATION DEPTH ([)
CIT TEL. NO. - MANHOLE REFERENCE '/ UPPER
_
REGISTRATION N0. f �/ %--SATE
❑ COUNTY
NO. DESCRIPTION OF WORK FEE _
-/ HOUSE SEWER CONNECTING TOv. TYPE OF OTION LENGTH FROM L
PUBLIC SEWER @ $3.50 ' ,c' CURB .. M.L.TO P.L. S
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 r q
OVERFLOW SEEPAGE PIT,DRAINFIELD R
° `q . C. NO.
E%TN_CESSPOOL,DRYWELL,M AN HOLE @ $2.00 CO. IMP. NO. f l JOB NO.
HOUSESEWER DISPOSAL
NESTING TO
DISPOSAL i ♦ / A�-Q�
PRIVATE SYSTEM C S 1.00 TRUNK PERMIT NO. ROAD PERMIT N0,
CONNECT ADDITIONAL BLDG. OR STATE ENCROACHMENT
WORK TO HOUSE SEWERCTa $1,00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 5 1]AND/OR
REIMBURSEMENT FEE
AUTHORIZATION xoxA1 FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEAPPROVALS DATE INSPECTOR'SSIGNA URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DW / e
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS �D/pY O 1CONNECT ADDITIONAL
OWNER. OR nn yJ�� /-_ BUILDING K,WORK
OWNERS AGENT t� c•iw q SEPTIC TANK,SEEP, PIT(S)
- ADDRESS ANO/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLCESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO
WITH ALL COUNTY ORDINANCES AND STATE. LAWS REGUALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STABANDON HOUSE SEWER
CALIFORNIA ORTHATI MTHELEG OWNER OF THE -
DESCRIBED RESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS❑ r
' SIGNATURE SEEP. PIT(s) Ll CESSPOOLS �/ }
OF PERMITTEE _
JOHN A LAMBIE, UNTY ENGINEER ��VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
/CR/
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