HomeMy Public PortalAbout9450 DAINES DR_Sewer__ %DEPARTMENT OF COUNTY ENT GLTFER SEWER-SEWAGE DISPOSAL
DI'VISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS 6?A,4515�7
FOR APPLICANT TO FILL IN LOCALITY
ADDRESS L/ �j- �� � NEAREST /�/
CROSS ST. �//
LOCALITY DISTRICT.N0. SERIAL NO. / PERMIT NO. C
NEAREST __ /; � 6 ,T®7 S
CROSS ST. J ---RE'GtttEI���VE---D BY Ready for Inspection DATE ISSUED
OWNER k Y /
ADDRESS7�,�> 'MAIL USE ZONE OCCUPANCY /_MA✓P T
'09 BK PG
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CITY ��J1�!�! 'El NO. /A "C/� `�®[3/J �`��910 O ....
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CONTRACTOR Co.-
1".NO.
ADDRESS JOB.N0.
CITY TEL.NO. — TRUNK PER NO.
STATE
REGISTRATION NO. ® COUNTY ROAD PERMIT NO.
LEGAL PERMIT NOROAGHMN�T
DESCRIPTION LOT N0.
BLOCK TRACea LQlze' INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT /fy 2 On NOW ON LOTS N-CHARGES
BUILDDI NGS
USE CONNECTION CHARGE FEE w
� - C7_
NO. ESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
JpOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPT NO. I ATE IBY
HOUSE SEWER CONNECTING TO f
NATE DISPOSAL SYSTEM 1.00 a
CONNECTADDITIONAL BLDG.OR EXCEP ION RECORDED
WORK TO HOUSE SEWER 1.00 / E7a
ALTER OR REPAIR EXISTING N0. DATE ~� I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 ONNECTION DATA
—SEPTIC TANK,SEEPAGE PIT OR — \
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 / MANHOLEREFERENCEEFERENCE LOWER
i TYPE OF C NNECTION LENGTH FROM
OWNERS PERMIT $ I 1 OO Y CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE I 00
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS PE OR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS............._......DAY OF...._.... �_...............__...19__ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.......................... BUILDING OR WORK
_ SEPTIC TANK,SEEP.PIT(S)
ADDRESS................_......_..._.._....................................................... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSESEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SIGNATURE `)j� / �,Oq/ SEEP.PIT(S)[:] CESSPOOLS E]
OF PERMITTEE..L%d/�!V'.. ....
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