HomeMy Public PortalAbout9720 DAINES DR_Sewer__ �• , 'TEMPLE CRTY
c SOB D APPLICATION FOR PERMIT
eeos a-se COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 26 04 .`L•5 T�
ADDRESS ,V C I
JOHN A. LAMBIE, County En weer
CASSATT D. GRIFFIN, Supt of Buildmq LOCALITY 416 6 1
FOR APPLICANT TO FILL IN
EAREST
CROSS ST AAA Q" S
LEGAL
DESCRIPTION LOT NO OWNER d J p
MAIL `1 /�� /\D D
BLOCK TRACT 7 ADDRESS /V�+ ,e - //r'i I N�Sry►_ p
SIZE OF LO Y /26 ' NOW ON LOTNO OF S CITY p�E 6 EL NO / O
USE OF
BUILDIN DISTRICT NO GROUP MAP PROCESSED BY
CONTRACTOR D _lk'r r PG e " — O 9-7 - at_t)JKi;
ADDRESS 6739MOV T/71- sr. CONNECTION DATA -
CITY � TEL NO t3 STATION 3 tS3. v DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO 2/ COUNTY LOWER
NO I DESCRIPTION OF WORK FEE
HOUSE SEWER
SEWER C.)
TO @ 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTIO LENGTH FROM
PITS AND/OR DRAINFIELD @c 0 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD () P/-1T-
E
XTN CESSPOOL DRYWELL @ 00
HOUSE SEWER CONNECTING TO P.C NO.
PRIVATE DISPOSAL SYSTEM @ too CO IMP NO JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ 600
11
L ER R DISPOSAL SYSTEM HOUSE @ 0 U STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S I PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE O 0 REIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEEI "NAMED CON-
TRACTOR TO CIONNE T THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY C OL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, EPAIR,SEWER OR
PLUMBING AND SEWERS E DISPOSAL SYSTEM d�l�, �fL
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR D 'PE DIS PLUG AND
LICENSED AS REOUI BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T T A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TIA ZP ER BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTE
MROBERT A. WOOD
TION
M.
0 p.
cs, cpgg SUPERVISINGSINGMECHANICAL ENGINEER -
Lti�o 4 7 6 1 G. MAY 15 1 0 D 5,0 0 `�'
C
S&E-68?11.99 APPLICATION! FOR PERMIT _ 1
e 3 E•8
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depcatment of County Engineer
County of Los Angeles BUILDINADDRESS G �2,0- 4 I ISI E'S
JOHN A. LAMBIE, COUNTY ENGINEER -A
® CASSATT D GRIFFIN, SUP T OF BUILDINQ LOCALITY 2 M P L E -7--
mi
w
FOR APPLICANT TO FILL IN gROSS S.�kcL_fq- S1� .
LEGALr OWNER �
( Z
DESCRIPTION LOT NO J
_
BLOCK TRACT MAIL t 5 ADDRESS _
NO OF BLDGS. CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF• I DISTRICT NO GROUP MAP
BUILDINGS PG -
CONTRACTOR t l _ ( �
ADDRESS �' CONNECTION DATA
STATION DEPTH
CITY TEL NO.FQ1 clI MANHOLE REFERENCE UPPER
9"i TATE
REGISTRATION NO S- 4--?,0 Ll COUNTY
NO DESCRIPTION OF WORK FEE
TYPE OF CONNECTIO - LENGTH FROM
Y. CURB Q q J
HOUSE SEWER CONNECTING TO M L TOP L
PUBLIC SEWER @ $3 50 )
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELDP. C NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO JOB NO
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 t 1 00 - I
EE
AUTHORIZATION TOTAL FREIMBURSEMENT FEE .
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPE�T,ORSS GNATURE
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 I - 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 ORDINANC ND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IIHEREBY CERTIFY TH ROPERLY REGISTERE AND/ R
LICENSED AS REQUIRED Y NGELES COU Y AN STATOF DISCONNECT PLUG AND ,
CALIFORNIA OR THAT A E LEGAL BOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT RTY^ _ BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS ElOF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINEER ALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
b 0 CASH
a LAC05 1 2 0D; DEE16I 4 4.50 2
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