HomeMy Public PortalAbout9319 DAINES DR_Sewer__ IS E-663 11-55 APPUCATMN FOR 11 E.RIIC T 1;1
DIVISION OF BUILDING ARID SAFETY SEWER SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDIN
ADDRSG 3 k QA 1�1 E' p
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY •J✓1�(� C> 17-1
NEAREST
FOR APPLIC_A1VT _Q FILL I1V � ceoss sr. t-T o tiJ �+
LEGAL Sr I O Of Exrej,T �
- - MAIL Rc�
[t DESCRIPTION LOT NO.`, [,�� OWNER ^'�
BLOCK TRACT r ADDRESS 3 n 1 �' t)4i AJ E�s b A-.:,
u 3 XI�O G NOW ONNO OF LOTd CITY TT&_N1 pLp_ CITY TEL. NO. AT (a -5"$1
' SIZE OF.LOT
USE OF LL I h) DISTRICT N0. •: :G-; ✓:
BUILDINGS Dw� w ROUP BK MAP/
CONTRACTOR ow AJ S& of �P�
ADDRESS 01 E• �bAIMMS &Lp CONNECTION DATA -
Ar46-5.S"7
�'y STATION DEPTH
CITY TEMPLE CTTy TEL. NO. Ar 4G-5.S I '+, MANHOLE REFERENCE�w �+ ,p UPPER
❑ STATE 'u JrT�A6� fSF� LOWER,
REGISTRATION-NO. ❑ COUNTY o �0.� A ^ J�• �h, ` ',�, _
NO. DESCRIPTION OF WORK FEE
TYPE OF OF CONNECTION ._ LENGTH FRIO# � .
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.f TOP.L.PUBLIC SEWER @ $3.50 �.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO. IMP. NO. - JOB.NO: L
�k
HOUSE SEWER CONNECTING TO d'$/Qj
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO V�C6✓
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT - .
WORK TO.HOUSE SEWER @ $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 $ 1 00
'. REIMBURSEMENTFEE
AUTHORIZATION TOTAL FEE 15-0
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -APPROVALS DATE INS iECTOR•S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER � 7•: ,L�.
_ �9 [,
SIGNED THIS �` DAY OF 19 J ^' CONNECT ADDITIONAL
OWNER ORi BUILDING OR WORK
OWNERS AGENT
SEPTIC TANK,SEEP, PIT(S)
ADDRESS .� 27 _ 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 '1 ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OFTHE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. �- BACKFILL SEPTIC TANKS❑
SEEP. PIT(S)-LI CESSPOOLS❑.
SIGNATUREt7 ITTEZ,;;
OF PERME l/� ./-d - -
JOHN A. LAMBIE, COUNTY ENGINEER VV. IDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
'te a3 3 1 1ZR FEB 8 5 l�a 4 bob CASH" _ "P.S.�.
CO3 5 1- �� FEB,?