HomeMy Public PortalAbout9716 DAINES DR_Sewer__ 76A6420 APPLICATION FOR E I.T .
IS&E•663 11.55
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of LOS Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER —ADDRESS
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CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY—^ -
CP.IIPI—L
NEAREST
FO,�t APPLICANT TO FILL IN ceOS,ST.
LEGAL ! OWNER �� �'-7 C_
DESCRIPTIONS .LOT No. '1 '
BLOCK - - TRACT- MAIL -
l �� `�-_' ADDRESS
SIZE OF LOT
90:OF BLDGS
NOW ON LOT . CITY TEL. NO.
> USE OF - DISTRICT NO. GROUP MAP
BUILDINGS I PG
Y CONTRACTOR ,
CONATEC3IOIU DATA
ADDRESS
STATIONC..-¢ 6/ DEPTH
CITY /1 , TEL. NO. MANHOLE REFERENCE �r � UPPER
LL...... ❑ STATE
�? REGISTRATION N0. ❑ COUNTY �I
No. DESCRIPTION OF WORK FEE
'
HOUSE'SEWER CONNECTING TO
TYPE OF CONNECTION LENGTH FROM �1
PUBLIC SEWER - @ $3.50 v Y. CURB .L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
+ - OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP, NO. 7OB NOO
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 _
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
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- .APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWERS
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL --
--✓ .
OWNER OR � BUILDING OR WORK
R OWNERS ..AGENT - SEPTIC TANK,SEEP, PIT(S)
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 AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND- SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY T T AM PROPERLY REGISTERED AN OR -
LICENSED AS REQUIRE BY/LOS ANGELES CO Y AND STA OF DISCONNECT PLUG AND -
CALIFORNIA OR THA I THE LEGAL ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDEN PERTY. t BACKFILL SEPTIC TANKS❑.
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE �¢ t
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
M. O. CASH
CH --
! 5 2 lU:; DEC16 4 4.50 19,