HomeMy Public PortalAbout9844 DAINES DR_Sewer__ 6,6 ,°
76A 642D APPLICATION F" PERMIT
64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
(jam //��
JOHN A. LAMBIE, County Engineer C✓X
WILLIAM A. JENSEN. Sup't of Building p r if1
4l'� C.1 L
FOR APPLICANT TO FILL IN
LEGAL '
DESCRIPTION LOT NO OWNER L.
MAIL
BLOCK TRACT g-'j ADDRESS
NO OF BLDG5
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS /D./y, (.,/,
CONTRACTOR
V�I �" y � I/'L L/'"' U' V (j PG
ADDRESS CONNECTI DATA
CITY /!LTJ )OaV SEL NO `- /� STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION O WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y URB P L M L TO P L
PUBLIC SEWER @ $5 00 a
SEPTIC TANK SEEPAGE PIT OR P C NO O
OB NO
PITS AND�OR DRAINFIELD EI000
CV
HOUSE SEWER INFIELD
TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ E3 00 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVER EAIEMEIT RECORD INSTR NO ATE V`
WORK TO HOUSE SEWER @ E3 00 L0
OVERFLOW SEEPAGE PIT DRAINFIELD fJJ
EXTN,CESSPOOL,DRYWELL MANHOLE @ $5 00 a
En
N HOUSEHWY OR ST WIDENING ZR pycance� c rcM @ $300
STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 21 00
AUTHORIZATION I TOTAL FEE Y J� CONNE ON CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONN R IMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT -
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
A
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RERA _
ccWZR ,R
CE
LINSED 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, THEZE DESCRIBED ESIDENTIAL PR ERTY ABANDON HOUSE SEWER
LSIGNATURE BACKFILL SEPTIC TANKS ❑
PERMITTEE �'� ��� SEEP PIT(S) ❑ CESSPOOLS ❑
OVM O CASH ALIDATION ROBERT WOOD
SUPERVISING MECHANICAL
NICAL ENGINEER
CK
Lr,Go o 4 1 0-106 DEC 2 1 0 D 5.00-