HomeMy Public PortalAbout9402 DAINES DR_Sewer__ D
S E-663 11.85. `1- APPLOATOOIIU FOR PERDC7D�'T
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DIIISION OF BUILDING AND•SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles 7A7DDRESS
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JOHN A. LAMBIE, COUNTY ENGINEER 1 10/� [ j Ltipij?�P - '�•��
® CASSATT D. GRIFFIN, SUP'T OF BUILDING �'
FOR APPLICANT b -CANT TO FILL IN ceoss sr.
LEGAL OWNER
P DESCRIPTION LOT NO, e"A✓-
MAIL
f BLOCK •TRACT � ADDRESS - G
- N0.OF BLDGS. ,JLC
SIZE OF LOT`�a%' ��� NOW ON LOT / CITY N0.
USE OF - DISTRICT NO GROUP MAP
BUILDINGS '!
BK PG
CONTRACTOR - - �
CONNECTION DATA
ADDRESS
STATION T DEPTH
CITY 4 TEL. NO •MA
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Hyl+ - N E REfERENCE;'�
TATE
REGISTRATION NO.1=-"' E /J :,-"V' ❑ COUNTY - R
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO - TYPE OF CONNECTION LENGTH FROM ,
1 Y. CURB P.L. M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00 ,
O V.ERF LOW.SEEPAGE PIT,DRAINFIELD P. C. NO.
EXT .-,CESSPOOL,DRYWELL,M'ANHOLE @ $2.00. CO. IMP. NO. - JOB NO. J (J ECJ
HOUSE SEWER CONNECTING T0* - /J A !? 2
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. "� L/ "r J
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $.1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
S WER OR DISPOSAL SY TEM @ $1.00 „ WASTE APPROVAL
A,eA CHARGES
_ - CONNECTION CHARGE FEE -
OWNER'S PERMIT . $ 1 00n'
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE- S
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON. APPROVALS DATE INSPECTORS 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 - :BUILDING OR WORK -
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I 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 SEW '
CALIFORNIA OR THAT 1 A&I THE LEGAL OWNER OF THE ABOVE ,
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESS.P00 LS❑. .
OF PERMITTEE 2 -
...
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIONROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK. b.0. CASH - -