HomeMy Public PortalAbout9827 DAINES DR_Sewer__ &E-6D
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APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL.
Deportment of County Engineer III 1 11111 119=1
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County of LOS Angeles BUILDING '7�2. 7 / 0 y�„t IN ES JOR
ADDRESS So �1
WM.J. FOX, COUNTY ENGINEER 4/,"/
CASSATT D.GRIFFIN, Sua'r OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST �, Al FE'S 7-
.
LEGAL jr /r
_DESCRIPTION LOT NO.tty J OWNER S a +,r 0t �
BLOCK TRACT O�� MAIL C Z 7 Al6
_ADDRESS Q R/amen
NO OF BLDGS / ���
SIZE OF LOT n �/� / NOW
/�O�N/'LOT CITY j,� TEL NO /
BUILDINGS �/ 19� �r /�C? DISTRICT NO GROUP BK MAP PG
CONTRACTOR ! I bl e AeL /_ P_' (�
ADDRESS 3 2t- N SA/V l � , AAIMA CONNECTION DATA L� rJ
CITY CAl.��A TEL NO 47b 77670 STATION /(/t��s DEPTH
❑ STATE MANHOLE REFERENCE /2 ) /I
REGISTRATION NO / } [ COUNTY Vt� LOWER
NO DESCRIPTION OF WORK FEE
• ,t HOUSEPUBLIC SEWEREW ER CONNECTING TO Q S 3 50 �® Y TYPE 0 URB jE CTIOP L MEL GTO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SISTEM 100 _ /
iCONNECT BLDG OR
WORK TO HOUSE SEWER 1 00 _L —_ CO. IMPS/ �76 JOB NO
O
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NOT/��
!DISCONNECT AND ABANDON SEWER STATE FROACHMEPoT
ANDNC
_/OR DISPOSAL SYSTEM 1 00 PERMIT NC
I SEPTIC TANY., SEEPAGE PIT OR ---
140
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
�CESSPOOL-DRYWELL
WASTE APPROVAL
!SPECIAL CONDITIONS ONLY 2 00 CHARGES
� 00
OWNER'S
PERMIT CONNECTION CHARGE FEE
- s
AUTHORIZATION TOTAL FEE �'f� REIMBURSEMENT FEE
l
TRACTORHAVE TTOS CONNECT DATE CO
ONNETONTRTHEAABOVECTED IYDESCR BED EXISTINGITH THE HEREIN A DWELLING APPROVALS DATE INS SECTOR'S SIGNATURE
TO THE PUBLIC EW
NEW HOUSE SEWER
SIGNED THIS DAY OF �- 19 �p A_ pt Le"-=-
INER !>ta�
CONNECT ADDITIONAL
NER_S AGENT
1 BUILDING OR WORK
GENT �"�+�'�' 'O1 � `
-Y®-.♦"/!-f�---� },t, _ - - SEPTIC TANK,SEEP, PIT(S) - .-
1RESS AND/OR DRAINFIELD
HEREBY-ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
0 STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR -
MBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
ENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND +�
LIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
SCRIBED RESIDENTIAL ;Y. {' s� BACKFILL SEPTIC TANKS❑
SEEP. PITS) ❑ CESSPOOLS '� � �•� 'S f- I3lJl+t.c
GNATURE l �'
7F PERMITTEE
_IAM J. FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR