HomeMy Public PortalAbout9933 DAINES DR_Sewer__ t r
6A642-62
7 D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST P
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT w--7/10
ADDRESS
NO.SIZE OF LOT NOWCITY TEL. NO.
SE OFDISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRALTO �ADDRESS CONNECTION DATA
STATION �i DEPTH
C Y EL. NG.�
n TATE MANHOLE REFERENCE we
REGISTRATION NO. !l COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
HOUSE SEWER CONNECTING TO y� Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00
CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N L
PRIVATE DISPOSAL SYSTEM @ S3.00 OCA
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER I EASEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE ®®
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTI G DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTOR'S SIGNAT RE
SIGNED THIS�DAY OF 19 - - - y,
OWNER OR NEW HOUSE SEWER � f ��
OWNERS AGENT 1 /' ��CV�/' �C� CONNECT ADDITIONAL b
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 15 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�TH=ATjLEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG ANRESIDE IN, THED ESIDENTIA ROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑ _.�
OF PERMrr EE BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOL :7.+.��.l!%
VALIDATION ROB RT' A. WOOD"
SUPERVISING MECHANICAL ENGINEER
CK. M.O. V
1 q �^� �}V 7
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