HomeMy Public PortalAbout9713 DAINES DR_Sewer__ 78A6420
6.889 f1-S>! APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING , y / 1 E-
JOHN A LAMBIE,COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY TE•M PLL C. +
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.LEGAL
-DESCRIPTION_ LOT NO OWNER
g MAIL
-BLOCK. TRACT- !� ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO. I GROUP MAP
BK PG
CONTRACTOR ( L +<
ADDRESS • - w /Ct—
CONNECTION DATA
STATION I• DEPTH
CITY (� TEL NO. (�,
_ MANHOLE REFERENCE � UPPER
STATEWf
REGISTRATION NO 5 ❑ COUNTY
NO DESCRIPTION OF WORK FEE
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HOUSE SEWER CONNECTING TO - TYPE OF.CONNECTION LENGTH FROM _
_PUBLIC SEWER @ $_3 50 -d Y' CURB /r l M L TO P LID
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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 Q $1 00 WASTE APPROVAL
CHARGES -
CONNECTION CHARGE FEE -
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTTOR=S'SG T U R E
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 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED .L ANGELES COUNTY AND STA E OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM E LEGAL NER F TH ROVE
DESCRIBED RESIDENTI RTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS) ❑ CESSPOOLS❑
OF PERMITTEE ,
JOHN A LAMBIE, COUNTY ENGINEER -NALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK d 0 CASH
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