HomeMy Public PortalAbout9921 DAINES DR_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST V
ADDRESS CROSS ST. V
LOCALITY DISTRICT N/0. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL USE ZONE OCCUPANCY MAP
ADDRESS BK PG
CITY TELAO.
CONTRACTOR CO.IMP. NO. " 2 7 6o '
ADDRESS
JOB.N0. ._,..
CITY TEL.NO. TRUNK PERMIT NO.
REGISTRATION N0. C7 STATE 3 `®
Q COUNTY ROAD PERMIT N0. 5
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. CHARGES
NOW ON LOT
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50 I RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM_ 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO' DATE 16Y
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I MANHOLE REFERENCE
UPPER �L
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 1 00 CURB -i1.L.. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE 11HAVE THIS DATE CONTRACTED WITH THE HEREAED
(` -
CONTRACTOR TO CONNECT THE ABOVE D SCRIBEDIEXNSTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF........................................19-.1----- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT------------------_-................._._. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS-------- -- ............. -----------•--------- ---------------- AND/ORDRAINFIELD
t HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND 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 I 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 DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE / SEEP.PIT(S)D CESSPOOLS
OFPERMITTEE*---------------- ............-_................--•--------......---
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