HomeMy Public PortalAbout9336 DAINES DR_Sewer__ 8642LA 4"2
76A APPLICATI N FOR PE IT
76u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS
LEGAL L
DESCRIPTION LOT NO. OWNER
p MAIL
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON
LOT CITY TEL. NO,
USE OF - DISTRICTNO. GROUP MAP - PRO SSE. BY
BUILDINGS
J� BK PS
CONTRACTOR
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
STATE LICUPPER
LICENSE NO., GLASS MANHOLE REFERENCE /_I? Y
(�/ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER C�
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O_
PITS AND/OR DRAINFIELD @ CO.IMP. NO. JOB NO. d
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONALF�9R AFFIDAVIT W�IYEN EASEMENT RECORD. INSTR. NO. DATE
WORK TO HOUSE SEWER @ 0
OVERFLOW SEEPAGE PIT.DRAINFIELD ~
EXTN..CESSPOOL.DRYW ELL.MANHOLE HWY.OR ST.WIDENING 6!J
ALTER.REPAIR OR ABANDON HOUSE d
SEWER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT
PERMIT NO. e
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s
'^ CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH E HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI E) EXISTING DWELLING
TO THE PUBLIC SE R. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS_1RX DAY OF "'
OWNER OR NEW HOUSE SEWER
OWNERS AGENT A►d
- __
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM 'PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COU AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA I AM THE LEGAL OWNER D INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE1 E RIBED RESIDE P P�.BTY. p ABANDON HOUSE SEWER
SIGN ATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATION
CK, M.0. CASH
7 8 1.'r--vJL 2.5 1 0 D
r?yz
TEMPLE C4TY
A842D
CEAPPLICATION FOR PERMIT
cEeoe a-sa COUNTYOF LOS ANGELES 1
DEPARTMENT OF CLS.p7t
NGINEER SEWER—SEWAGE DISPOSAL +
BUILDING AND SVISION BUILDING
ADDRESS
IO IN A. LAMBIE, Engineer
CASSATT D. GRIFFIBuildiag LOCALITY
NEAREST
FOR APPLI T O FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N
'tl 19
BLOCK TRACT MAIL
IQ
ADDRESS � `
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITYc,704 EL. N0.
USE OF I� DISTRICT NO. GROUP MAP PROCESSED BY
F_ BKBUILDINGS
PG
CONTRACTOR b
ADDRESS CONNECTION DATA
CITY TEL.N0. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION Ne. COUNTY LOWER—
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM.
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ,
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 - CO.IMP.NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT -
SEWER OR DISPOSAL SYSTEM @ $1.00 _PERMIT NO.
INDUSTRIAL - -
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I REIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEREINAMED CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(5) _
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
_ ❑
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 REQUI BY LOS ANGELES COUNTY ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH 1 AM THE LEGA WNER THE ABOVE
DESCRIBED RESIDENT L OPERTY. BACKFILL SEPTIC TANKS ❑
SEEP. PIT(S) [ICESSPOOLS ❑
SIGNATURE
OF PERMITT
®P V ATI SUPERVISING MECHANICAL. ENGINEER
BERT A. WOOD
C6, tl.o. CASH
5s6. 4 DEC 11 1 D. 11500A