HomeMy Public PortalAbout9313 DAINES DR_Sewer__ &ED
5& -683 11.55 APPLICATION FOR PER�WU�T
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DIVISION OF BUILDING AND SAFETY SEWER-S EYWAG E DISPOSAL
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Deportment of County Engineer
County of Los Angeles eu1LDING`
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY NEAREST /
FOR APPLICANT TO FILL .IN caoss ST. "
LEGAL ® OWNER '
DESCRIPTION LOT NO. B
BLOCK, TRACT�' W, � 4C7 ADDRESS ' -
��,( .I'..Q NO. OF BLDGS. CITY TEL. NO.
SIZE OF-LOT n 66..�� NOW ON LOT
:. :'s:'S•4, -_.:. '-:.rfi ti C-. . - . a'HM ,moi-. :
USE OFDISTRICT NO. GROUPV MAP
BUILDINGSBK- pp
CONTRACTOR �•-"
ey/ S -31
CONNECTION DATA 17ADDRESS 3 6� DEPTH 0 P—
CITY - TEL. NO. �'r�Q a STATION .
MANHOLE REFERENCE UPPER
C] STATE �ry
REGISTRATION NO. / I/ � ❑ COUNTY
NO. DESCRIPTION OF WORK FEE '
HOUSE SEWER CONNECTING TO �. TYPE OF CONNECTIO LENGTH FROM
-PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 '
OVERFLOW SEEPAGE PIT,DRAINFIELD 1� - C. No.s .
CO. IMP. N0. OB N0.
EXTN.,C ESSPOOL,DRYWELL,MANHOLE (@ $2,00 f� -
HOUSE.SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER Qi $1.00 PERMIT No. - - -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM a $1.00. WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
REIMBURSEMENT FEE -
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER. OR �V .BUILDING OR WORK
h•'i
OWNERS AGENT _ - r - SEPTIC TANK,SEEP,PIT(S)
ADDRESS - AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE, THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
.. WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER' OF THE ABOVE o
DESCRIBED RESIDENT AL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS[:1
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OF PERMITTEE
Lai
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION
ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CASH -
.1 8' 0-8 0 OCT 29 4 4.50