HomeMy Public PortalAbout9710 DAINES DR_Sewer__ 13 E-613 E•88
8 APPLICATION FOR PERMIT
& 9 if•SS 7
DIVISION OF BUILDING-AND SAFETY SEWER-SEWAGE DISPOSAL 1
Deportment of County Engineer
County of Los Angeles BUILDING Ci.1 t �q(U
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JOHN A LAMBIE, COUNTY ENGINEER N
ADDRESS V 5
® _ CASSATT D GRIFFIN, SUP'TOF BUILDING LOCALITYEAIEIT
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FOR APPLICANT TO FILL IN CROSS ST, �1tf L� c!
LEGALOWNER ^�
DESCRIPTION LOT NO T2 C#
MAIL _
BLOCK TRACT ADDRESS
NO OF BLDGS CITY TEL NO
SIZE OF LOT - NOW ON LOT
USE OF DISTRICT NO GROUP MAP
BUILDINGS PG
�7'�
CONTRACTORZ.
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ADDRESS 6 5 a.11)zI(� "/►/ !.� CONNECTION DATA
CITY co V!/�/� TEL NO STATION . ��7/'D DEPTH
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MANHOLE REFERENCE �y
/ STATE Cf LOWER
REGISTRATION NO - /S� ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION,-A LENGTH FROM
PUBLIC SEWER @ $3 50 � Y. CURB r P M L TO P L
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD _ - - P C NO:
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO - ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT - -
WORK TO HOUSE SEWER Q $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
AUTHORIZATION I TOTAL FEE ozsryV REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- APPROVALS DATE INSPECTORSSIGNATUR_E-
.�-�-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 4�a
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL J�
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 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 THA I PROPERL REGISTERI;) AND/OR
LICENSED AS REOUIRED ANGELES C UNT X766 STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT HE-_LEG OF T�1E ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT BACKFILL SEPTIC TANKS❑ `
SIGNATURE 1 SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE -
JOHN A LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N 0 CASH -
y 5 12 2 DEC 16 4 450 ,