HomeMy Public PortalAbout9962 DAINES DR_Sewer__ DEPAItriVIENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS 2a I H s Y
FOR APPLICA TO FILL IN I LOCALITY �-
BUILDING QQ • NEAREST
ADDRESS L ��� .�� CROSS ST.
+----�--� DISTRICT NO. SERIAL NO. PERMIT NO.
LOCALITY ( -G e A 3 7 ,76 / C
NEAREST � I'1 J
CROSS ST.
�+ R EIVED 'Y R ady for Inspection DATE ISSUED
OWNERMAIL
ADDRESS USE ZONE OCCUPANCY BK MAP
CITY TEL.NO. - -j Z
Yt� I I PG 7
CONTRACTOR
,CO.IMP.NO. -
ADDRESS
JOB NO.
CITY TEL. TRUNK PERMIT NO.
REGISTRATION NSTATE0. COUNTY ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK . TRACT INDUSTRIAL _w
WASTE APPROVAL
SIZE OF LOTNO.BF BLDGS.
N W ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DES IPTION F WOR NFEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER 3.50
HOUSE SEWER CONNECTING TO RECEIPT N0. I DATE I BY
PRi VATE DISPOSAL SYSTEM 1.00 i
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO ( DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AHD/OR DRAINFIELD 2.00 STATION / < Oo DEPTH
CESSPOOL—DRYW ELL
SPECIALCONDITIONS ONLY 200ANHOLEREFERENCE
t OWER
TYPE OF CONNECTI LENGTH FROM /7 Q/
OWNERS PERMIT $ I Op
Y. CURB P.L. M L.TO P.L. G T
„
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HERE N NAMED'
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS PECTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS...... __ _-DAY OF------ ___._ r?_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS A NT_--------_-_-a ------ :, ____. -__. _ BUILDING OR WORK
c TANK,SEEP.
ADDRESS--- -.• --�.--_-_S�._ ..•__...__._....---..-•------ `•— AND/OR DRAINFIELD PIT(S)
I•HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL El 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
AND/OR LICENSED AS REQ IRE BY MOS ANGELES COUNTY, DISCONNECT PLUG AND
AND STATE OF CALIFORNI R T 1 AM T,,yyE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE !1 E 1 ENT <PROPER Y' BACKFILL SEPTIC TANKS
,�, E / SEEP.PIT(S)E] CESSPOOLS
SIGNATURE ' -
OF PERMITT E - -� - -...... ._. ..------
76AG42D 663 I/ _ i
C�
3-E4
76A643-64
APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
TE
1009- 1.4111!11ej�o AA -7111/y
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FML IN
CRO ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK -' TRACT ADDRESS
NO OF D
SIZE OF LOT NOW ON LOT CITY NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
/�' BK PG
CONTRACTOR
J � 7
ADDRESS CONN CTION DATA
CITY NO STATION ` DEPTH D
STATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY Z 1 LOWER
NO DESCRIPTION OF WORK FEE TYPE O EC O LENGTH FROM
HOUSE SEWER CONNECTING TO Y C PL ML TOP L
PUBLIC SEWER @ E5 00
SEPTIC TANK,SEEPAGE PIT OR (�7,(/ JOB NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE a'
WORK TO HOUSE SEWER @ $300 ���--0...
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MANHOLE @ E5 00
ALTER REPAIR OR ABANDON HOUSE HWY ORST WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S z 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC S R DATE INSPECTOR'S SIGNATURE
SIGNED THIS QAY O 1
OWNER OR `� NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
AzeffdBUILDING.QRsriOR'!h n �"��,�
ADDRE SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE-THAT
I E D
HIS A P CA 10 AND/OR RAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY 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 THAT I AM T�.IE EGAL NER F, AND I TEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABQVDE�]) EN P OPE Y ABANDON HOUSE SEWER
SIGNATURE /UR '(�/}/ / BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP PIT(S) ❑ CESSPOOLS
l I
VALM 0 CASH ROBERT WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER