HomeMy Public PortalAbout10955 DANBURY ST_Sewer__ ' APPLICA ION FO PERMIT
csede'a-ee COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DMSION 0UI LDING
ADDRESS
ISSA A. LAIMBIE,GRIFFI Couut'y of Buier
lding
_ G--�..-
CASSATL D._GHIFFIN. Supt of SuildiaQ LOCALITY' '
NEAREST
FOR APPLICANT TO FELL IN CROSS ST. a
LEGAL
[DESCRIPTION LO7 N0. � OWNER
LOCK TRACT MAILADDRESS
LDGZE OF LOT NOW ON LOT CITY TEL. NO..
SE OFDISTRICT NO. GROUP MAP PROCESSED BY
UILDINGSONTRACTORDDRESS CONNECTION DATA I—I TEL.N0: �,.� STATION DEPTH V
ATE MANHOLEREFERENCE HP
REGISTRATION N0. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $3.00 Z�J
SEPTIC TANK.SEEPAGE PIT OR TYPE OF CONNECTION LENGTHTO FP.L.:
ROM
M
PITS PND/OR DRAINFIELD @ $3.00 Y. CURB P.L. .L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ 82.00
PRIVATE DIISPOSAL SYSTEM ER CONNECTINGTO @ $1.00 CO.IMP, NO. JOB NO. } r
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00
TRUNK PERMIT N0. ROAD PERMIT N0.
@
ALTER.REPAIR OR ABAN OON HOUSE - STATE ENCROACHMENT .
.SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. - -
INDUSTRIAL
' WASTE APPROVAL
� CHARGES
OWNERS PERMIT g. 2 DO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF-19—
NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
'I HEREBY ACKNOWLEDGE THAT 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 ALTER.REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
CT PLUGHOUSE AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
WER
DESCRIBED RESIO IAL PRO RTY. BACKFI LL SEPTIC TANKS ❑
SIGNATURE
// .SEEP. PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
0. CASH
WOOD ,
crc. Y.o, sx - SUPERVISING MECHANICAL ENGINEER
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