HomeMy Public PortalAbout10945 DAINES DR_Sewer__ 76A 632D . CE808 - 9/73 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE D POSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
ADDRESS
LOCALITY
NEAREST
FOR AT CANT TO FILL IN GRD55 5T.
EGAL
DESCRIPTION LO OWNER
y MAIL Q
BLOCK TRACT / ADDRESS
NO. OF S
SIZE OF LOT
X NOW ON LOTNO.
USE OF
BUILDINGS DISTRICT NO. GROUPMPP CESSEp BY
6 /� O /( BK PS
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CONTRACTOR /` IA- £'wee. �� ( �J(J j-
ADDRESS /ZCONNECTION DATA
CITY I� C 'f TEL. NO. r7 (�r LS l STATION DEPTH
STATE 'LIC _ MANHOLE REFERENCE
LICENSE NO., CLASS
NO. 1 DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO /' Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 C/ 'y C
V�l..��
SEPTIC TANK.SEEPAGE PIT OR �Og ryO
PITS ANO/OR DR AINFIELD $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL SLDG.OR AFFIDAVIT I WAIVillUSu[xT RECORD.INSTR.NO. DATE 11
WORK TO HOUSE SEWER $3.00 1
OVERFLOW SEEPAGE PIT.ORAINFIELO V
EXT N,.0 ESSPOOL.DRYWELL. f5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM Q f3.00 STATE ENCROACHMENT
MANHOLEPERMIT NO. W
$) 00 INDUSTRIAL d
WASTE APPROVAL y
Z
-
OWNER'S PERMIT s 5roD CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1HAVE 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 INSPECTOR'S NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE TAT HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYW ELL
PLUMBING AND SEWERS. ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLE COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCAN N, H THAT I AM TXE LEGAL NER OF, ANO INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE THAT
CRIBED IOEN - L P PEj
ABANDON NOVSE SEW ER
SIGNATURE BACHFILL SEPTIC TANKS ❑
OF PEYMRTE SEEP.PIT_IS) ❑ CESSPOOLS ❑
VALIDATION CK, M.D. cnsH
5 8.5�;nm: 24 l.0 1 5.0 0 osd
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