HomeMy Public PortalAbout9708 DAINES DR_Sewer__ 5S&E-6D53 11.55 APPLICATION FOR Etl
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING q-1 p
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® - CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY 1�9_A PLS' C
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER 0 T!s C�-�
DESCRIPTION LOT N0.
BLOCK TRACT - �, AD R
ADDRESS
NO. OF BLDGS. CITY TEL. NO. `
SIZE OF LOT NOW ON LOT
USE
—BUILDINGS DISTRICT NO. GROUP MAP '
N CONTRACTOR p _I
S L IL Com' I
. SPG
ADDRESS �e�.� ('0 .�. CONNECTIOPI DATA -
STATION DEPTH
i; CITY TEL. N0. ' MANHOLE REFERENCE
e' �7 ,7 STATE - 6 ""��'� LOWER
REGISTRATION NO. �S ❑ COUNTY i• .
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB -M.L.TO P.L.
_ PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR .
PITS AND/OR DRAINFIELD @ $3.00 - p
OVERFLOW SEEPAGE PIT.DRAINFIELD P. C. NO. �y
EXTN.,CESSPOOL,DRYWELL,MANHOLE n $2.00 CO. IMP. NO. JOB NO. rl
a -HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. - ROAD PERMIT NO. -
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
f
CONNECTION CHARGE FEE
OWNER'S PERMIT 1 00
AUTHORIZATION TOTAL FEE " REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I` APPROVALS DATE INSPECTOR'S.SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. tp NEW HOUSE SEWER -
SIGNED THIS DAY OF 19 -�
'?a CONNECT ADDITIONAL
OWNER OR h` BUILDING OR.WORK
OWNERS AGENT SEPTIC TANK,SEEP, PITS) _
ADDRESS - AND/OR DRAINFIELD -
1 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 ND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT AM ROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED B LO GELES COU TY ND ST F
CALIFORNIA OR THAT I AM LEGAL OW R F .ABOVE _ ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA R BACKFILL SEPTICTANKS❑
SIGNATURE SEEP. PITS) ❑ CESSPOOLS❑
OF PERMITTEE -
JOHN A. LAMBIE, COUNTY ENGINEER ALID TION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
K M.O. CASH -
. a .
A 5 1 2 3u- DEL 16 44.50 0