HomeMy Public PortalAbout9821 DAINES DR_Sewer__ -64
76A6423-64
APPLICATION FOR ,PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE .DIS OSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN,, Sup't of BuildingIr
' LOCALITY '
NEAREST
FOR APPLICANT TO FILL-IN `ROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER ,
MAIL
BLOCK TRACT Q ADDRESS
NO OF BLDGS. -
SIZE OF LOT NOW ON LOT CITY TEL,ANO
USE OFDISTRICT.N O. GROUP MAP' PROCESSED- Y
BUILDINGS '
a, BK PG
CONTRACTOR f G7
ADDRESS CONNECTION DATA
STATION ' r DEPTH
CITY EL. NO. , _
STATE MANHOLE REFERENCE ���w
REGISTRATION NO. COU NTV /' LOWER
NO. DESCRIPTION OF WORK' FEE i TYPE OF CO ECTION LENGTH FROM L
HOUSE SEWER CONNECTING TO $5.00 G Y. C P.L. M.L.TO P.L.
PUBLICSEWER
P.C.NO,
SEPTIC TANK,SEEPAGE PIT OR 0
' PITS AND/OR DRAINFIELD CO.IMP. NO. JOB NO,
� E10.00 ,r�
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. //\ V
PRIVATE•OISPOSAL SYSTEM - @ $3.00 4�J
CONNECT ADDITIONAL BLDG.OR - AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR,NO. DATE
WORK TO HOUSE-SEWER $3.00 O
OVERFLOW SEEPAGE PIT.DRAINFIELD _
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ E3:00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 2 Oo
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN' AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS - D 19_
OWNER OR � NEW HOUSE SEWER ! ✓�" �
OWNERS AGENT ' ( CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS " - - `
'SEPTIC TANK.SEEP,PIT(b)
I HEREBY ACKNOWLEDGE THAT I HAVE,READ THIS APPLICATION AND/OR DRAINFIELD
.AND STATE THAT THE ABOVE IS CORRECT AND AGREE'TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING '
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO. DISCONNECT PLUG AND
RESIDE IN, THE VE DESCRIBED RE ENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM ITTE SEEP•PITS) ❑'CESSPOOLS ❑ �� �rEL•L/'% ..
(/-t(ALIDATION ROBERT A. WOOD
�ISUPERVISING MECHANICAL ENGINEER
M
- CK. .O. CASH