HomeMy Public PortalAbout9969 DAINES DR_Sewer__ DEPAIVIPMENT OF COUNTY ENGINEER, SEWER-SEWAGE DISPOSAL
,-,DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION -
4; y COUNTY OF LOS ANGELES
?� WILLIAM J. FOX, COUNTY ENGINEER I` BUILDING
ADDRESSpS
FOR APPLIC NT TO FILL IN LOCALITv-,'C
/ / /_ NEAREST
ADDRE
ADDRESSS � sL � � CROSS ST. C41 A N
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=/ l DISTRICTN0. SERIAL NO. PERMIT NO.
LOCALITY t c
NEAREST A S
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CROSS ST.
CEI ED BY Ready for Inspection A E ISS ED
OWNER MAIL // 41,CA2
ADDRESS (D `� USE ZO IE OCCUPANCY MAP
BK PG
CITY TEL.NO. �/
CONTRACTOR CO.IMP.N0. 2 ��
ADDRESS JOB NO.
CITY TEL.NO. TRUNK PERMIT NO.
REGISTRATION O. J CSOUNTY ROAD PERMIT NO. S-
LEGAL -STATE
DESCRIPTION LOT NO. PERMIT NO.
- i
BLOCK TRACT I INDUSTRIAL
N0.OF BLDGS. 4 -WASTE APPROVAL
SIZE OF LOT �QX a a N.OW ON LOT CHARGES
USE OF
BUILDINGS I CONNECTION-C`ARGE FEE
NO. DESCRIPTION OF WORK FEE } s
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
I
PUBLIC SEWER @ $ 3.50 .� RECEIPT NO. yDATE•-"— I BY
HOUSE SEWER CONNECTING TO $ �/
PRIVATE DISPOSAL SYSTEM 1.00 9
CONNECT ADDITIONAL BLDG.OR ( %EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 1
ALTER OR REPAIR EXISTING NO. I 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 AND/OR DRAINFIELD 2.00 STATIONI T� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY. 2.00 { ��p1ANHOLE REFERENCE
I i a-F •MEIrE$ LOWE
TYPE OF ON ECTION LENGTH FROM
OWNERS PERMIT 1 UO ! RB M.L.TO P.L. -
AUTHORIZATION 4 TOTAL FEE rJ G
1 HAVE THIS DATE'CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECT OR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER II
SIGNED THIS___.>� DAY OF ... ..__..J�.: 19�L NEW HOUSE SEWER
OWNER OR �,/t M - CONNECT ADDITIONAL
OWNERS AGENT-/4.e0 -'-
SEPTIC
GENT_'-""L�`�. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS ...... - - - - -.._.-.. - ---------- AND/OR DRAINFIELD
i
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL I]
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 1 AM PROPERLY REGISTERED
R LICENSED AS REQUIRED BY LOS ANGELES COUNTY., USE AND
AND/ODISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNSEWER
-
ER OF THE ABOVE DESCRIBED RESIDENTIAL.PROPERTY. BACKFILL SEPTIC TANKS�
a �� SEEP.PIT(S)F] CESSPOOLS
SIGNATURE
OF PERMITTEE._.c1rSL
76A642A 663 7/53