HomeMy Public PortalAbout10554 DANBURY ST_Sewer__ EI38 319-B3
76A6D APPLICATION FOR PERM(T
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O r
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. IENSEN, Supt of Building y—.�
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROS!
LEGAL
DESCRIPTION LOT NO. OWNER MA'L
BLOCK TRACT ?/ G O I ES$S� f
NO. OF SLOGS.
512E OF LOT NOW ON LOT CITY r G. TEL. NO.
USE DI DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
c BK PG
CONTRACTOR S Q� L'-�-. •-� GLS
A DOREss Z CONNECTION DATA
CITY TEL OSTATION 2408 DEPTH
�,/J/� r/y ❑ TATE vJ tl�R
REGISTRATION NO, fLV i�J i/'-� O COUNTY MANHOLE REFERENCE D. J IJ ' / LOWS
S
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION JO LENGTH FR M
RDUSE SEWER CONNECTING TO �_Q Y. CURB P.L. M.L.TO P.L. }
PUBLICSEW ER 39.0D11-
SEPTIC TANK.SEEPAGE PIT OR P C NO /.. �j/ O O
PITS AND/OR DRAINFIELD @ SIO.DD p CO.IMP. NO. Jog NO. `! /<O
U
NO ATE DIBE SPOSAL
NESTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 33.00 N.
CONN ECT ADDITIONAL BLDG,OR AFFIDAVIT MY OSLVE.T RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 F
OVERFLOW SEEPAGE PIT.OR41MFIELO WV
EXTN.,CESSPOOL.DRYWELL.MA RHO LE CD $3.00 p,
ALTER,REPAIR OR ABANDON HOUSE HWY,OR ST.WIDENING yI
WE
DRDISPOSALSYSTEM $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PEAMIT 5 z 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Lo
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC EWER. APPROVALS DATE INSPECTOR' IGNATURE
SIGNED THIS AY OF 19
OWNER OR NEW HOUSE SEWER - T
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS GILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION PND/OR DftAINF1ELD
AND STATE THAT THE ABOVE IS
CORRECT AND AGREELY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REE CoCOMGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRVWELL ❑
HEREBY CERTIFY THAT I AM PROPS EGISTERE AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIRED B ANGLES NTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I TH LEGAL O ER AEPT
RESIpE IN. THE ABOV DES IBEO qE ENTI NECT PLUG AND
N HOU5ESEWER
SIGNATURE i L SEPTIC TANKS ❑
OF PERMITTEE f51 ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
JjT2 0 7 3G JUL31 1 0 D 7.00-