HomeMy Public PortalAbout10784 DAINESWOOD DR_Sewer__ CE 2/TO
76A 6 B2D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION a 'L LNc
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS ,
COLEMAN W. JENKINS. SUPT. OF BUILDING /
LOCALITY /
NEAREST
FOR APPLICANT TO FILL IN
CRO
(PRINT OR TYPE ONLY)
GAL
DESCRIPTION LOT NO. OWNER /
MAIL j
BLOCK �� TRA CT ADDRESS�v
Q NO. OF SLOGS.
SIZE OF LOT O / D NOW ON LOT CITY / X TEL. NO. SJ
USE OF
.H DISTRICT NO. GROUP CLA55 MAP SSED BY
BUILDINGS
!/1--. BY. pS �/ I
CONTRACTOR /
ADDRESS CONNECTION DATA
r
CITY TEL, NO. STATION zpj PTH _ly / �J
STATE LICMANHOLE REFERENCE UPPER
LICENSE NO. CLAS$ LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
EC EWER
® S4.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD ® S10.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. }
_PRIVATE DISPOSAL SYSTEM S3.DO d
CONNECT ADDITIONAL Lb1HR AFFIDAVIT Alv .5[YEX RECORD.INST..NO. GATE
WORN TO HOUSE SEWER ® 53.00 G U (J
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MAN FO LEO 55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT LJ
PERMIT NO. W
d
INDUSTRIAL y
WASTE APPROVAL Z
OWNERS PERMIT s 00
CONNECTION CHARGE FEE CHARD ES
AUTHORIZATION TOTAL FEE 9160
I HAVE AT THIS DATE A CONTRACT WITH TFE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC 5/Fj/yyE q/, "� /� APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS�/ay DAY OF ��J 19
OWNER ORO NEW HOUSE SEWER
AOWNERS AGENT CONNECT ADDITIONAL
ADDRESS/ BUILDING OR WORK
J SEPTIC TANK.SEEP,PITISI
I HEREBY ACK WLEDGE THAT HAVE READ THIS APPLICATION PND/OR GRAINFIELD
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 SEl DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TODISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE B ACNFILL SEPTIC TANK 5 ❑
OF pERMfTTEE_ /
SEEP.PIT I51 ❑ CESSPOOLS ❑
/ VALIDATION JACK R. ALLEN
UK. 1 M.O. CASH SUPERVISING MECHANICAL ENGINEER
836i. iAY 610 0 6.0 0 ,&9d