HomeMy Public PortalAbout9938 DAINES DR_Sewer__ CEfIU-63
76A642D APPLICATION FO PERM[T
64
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
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAI
BLOCK TRACT *v ADDRESS 3C/
49 NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY �, TEL N 1j
USE OF ^
BUILDINGS 1 DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR ' 0
ADDRESS IJ CONNECTIO14 DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY ,LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIONH FROM
HOUSE SEWER CONNECTING TO Y CURB PL M L TO r
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR P C NO d
CO IMP NO JOB NO Q
PITS AND/NOR DRAINFIELD C $10 00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVI WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELD gTjW
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE (n
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 ARGES
AUTHORIZATION TOTAL FEE 1
CONNECTION CH FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SE DATE INSPECTOR'S SIGNATURE
SIGNED THIS 1 1,e2 DAY O 19
OWNER OR NEW HOUSE SEWER e
OWNERS AGENT
ON ECT ADDITIONAL
' BUILDING OR WORK ¢
ADDRESS j�e
r f T
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS API AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TOO CnMSEPTIC TANK SEEP, PIT(S)
COM Y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGUL ING
PLUMBING AND SEWERS CESSPOOL ElDRYWELL [:1
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEW
A 'DISPOSAL SYSTEM
CALIFORNIA OR THAT I M,THE LEGAL OW , AND NTEND TO CONNECT PLUG AND
RESIDE IN, THE ABOV ESCR D TI PR RTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS ❑
( VALIDATION ROBERT WOOD
M O CASH
SUPERVISING MECHANICAL ENGINEER
CK �
7 5 9 0 APR 1 3 1 0 D 55.0 0-