HomeMy Public PortalAbout9814 DAINES DR_Sewer__ r
41)EPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
BUI
WILLIAM J. FOX, COUNTY ENGINEER I ADD EISS
FOR APP I NT TO FILL IN LOCALITY
BUILDING NEAREST Jr
ADDRESS CROSS ST
LOCALITY * DISTRICT NO. SERIAL NO. nn/PERMIT NO. c
NEAREST V A 307-slO ✓ ��� S
CROSS ST
REC VIED BY Ready for Inspection DATE ISSUED
OWNER //— ---,)
i
MAIL USE ZONE OCCUPANCY MAP
ADDRESS / BK PG
CITY TELAO. i OD
CONTRACTOR CO.IMP NO
ADDRESS 7`�_ �� JOB NO
CIT
, '•Y/AO,�" TELL..Neo,I/f.-Q ,f'3 TRUNK PERMIT
REGISTRATION-NO 1 �ff d C r Y ROAD PERMIT NO
LEGAL STATE ENCROACHMENT\ /
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT / INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT ` QX/z () NO.OF NOW ON LOTS CHARGES/
USE OF
BUILDINGS CONNECTION CHARGE FEE x
NO. DESCRIPTION OF WORK/- FEE \
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 RECEIPT NO. I / DATE \I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM / 1 00 \
CONNECT ADDITIONAL BLOB.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER i 1 00
ALTER OR REPAIR EXISTING NOM DATE I BY\
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAI NFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y CURB P L M L.TO P L.
AUTHORIZATION TOTAL FEE 2 06
1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPEC OR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS...._............ DAY OF----_-_----- NEW HOUSE SEWER /, ,� .� tG ,3 �
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT............................. - BUILDING OR WORK
ADDRESS._ ___.--.__-__.__--.._..._.-_- __._............._-_--._-...---._--_. SEPTIC TANK,SEEP.PIT(S)
- AND/OR DRAINFIELD
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL F] DRYWELL E]
CAT
IONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE CRIBED ffSIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E
SIGNATURESEEP.PIT(S)[] CESSPOOLS
OF PERMITTEEf.- - --- --- - - -
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