HomeMy Public PortalAbout9915 DAINES DR_Sewer__ CE8°91°, - APPLICATION FOR PERMI-
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6.• COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
I DE RTMENT OF COUNTY ENGINEER
UILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building r
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST /
LEGAL
DESCRIPTION LOT NO OWNER J �•(
/� /�j�� MAIL
BLOCK TRACT [/ C/Y ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
l� I of 25-, z 6�14 a4e
ADDRESS Z� �"� CONNECTIO DATA
CIT1(:27
nn j (' L NO ZSI STATION DEPTH
" \� E
UPPER
�'� ATE
REGISTRATION NO Cr ^� COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 �-
SEPTIC TANK SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ 31000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ S3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT I RECORD INSTR NO TE DAj�
WORK TO HOUSE SEWER @ $3 00 U
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL,DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE STA OR C WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ i 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FE
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CO T ITH EREIN NAMED CON-
TRACTOR TO CONNEC T ABOV DESCRI D EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY F �- 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORS CE ND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ElDRYWELL El
I HEREBY CERTIFY HAT M OPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS REOUI D BY L S GLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA I AM H L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE E D C B SI IAL PROP TY ABANDON OUSE SEWER
SIGNATURE ILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
DCKVALIDATION ROBERT A. WOOD
M O - cnsH SUPERVISING MECHANICAL ENGINEER
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