HomeMy Public PortalAbout10940 DANBURY ST_Sewer__ 7GA042D APPL�C� riON
FO PERMIT
caeoe'a.sa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER ...... . . _ . .. .. ...,._._ —
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
rrOHN A. rBIFE, CouvtF Eng�nevT
ClSSSATT D. GRIFFIN, Supt of euildivq LOCALITY
. .. NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL J OWNER
DESCRIPTION LOT N0. (>q
BLOCK TRACT lJLJ 3 MAIL
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT / CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAPK OCESSED BY'
D Bt'f PG
CONTRACTOR �'
ADDRESS CONNECTION.DATA
CITY TEL N0. ,��(y` STATION a ?' S DEPTH L
qq TE MANHOLE REFERENCE PPER
REGISTRATION '0./ (� O{..� COUNTY ', _
NO. DESCRIPTION OF WORK FEE /L22
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM +7
SEPTIC TANK,SEEPAGE PIT OR Y. CURB .L. M.L.NGT
P.L.
PITS AND/OR DRAINFIELD @ S3.00 _
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB N0.
WORK TOT ADDITIONAL BLDG.
CDG.OR @ SI.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERrS PERMIT §r-2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - A PROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA OF 19_ NEW HOUSE SEWER 20'/�/)
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
• 1 HEREBY ACKNOWLEDGE KAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING f ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE -.
DESCRIBED RES TIAL P PERTY. /�' BACKFILL SEPTIC TANKS ❑
SIGNATURE J SEEP. PIT(S) [ICESSPOOLS El
OF PER)ITT
®• 0. ROBERT A. WOOD
QK, Y.o. UBN SUPERVISING MECHANICAL ENGINEER
Lf'd�2 4 , 9 sura 2 0 1 0 D 5.0 0