HomeMy Public PortalAbout10122 NADINE ST_Sewer__ D
8&B 6631185 APPLICATION FOR PERMIT 1
DMSION OF BUM= AND SAFi:'1'Y SEWER—SEWAGE DISPOSAL
Department of County Engineer
County Of Loa Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER
® e.
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CC..ss sT
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY71 G TE a 3
USE DISTRICT NO GROUP OUP MAP P
NGS I �_
BK 6
CONTRACTOR �
CONNECTION DATA
ADDRESS
�� STATION �f�+ ♦ DEPTH
CITY TEL NO
4 ^ MANHOLE REFERENCE p� a UPPER
REGISTRATION NO / �� / ❑ COUNTY V ,
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO + TYPE OF CONNECTIO LENGTH FROM
PUBLIC SEWER @ $3 50 f Y CURB P L M LH
L
SEPTIC TANK SEEPAGEPIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $200 CO IMP NO 4991ITO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERM S 00
Ja REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE i
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING01
TO THE PUBLIC SEWE NEW HOUSE SEWER
SIGNED THIS Y 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGE N SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE-LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I 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 M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) [I CESS
POOLS❑
OF PERMITT
JOHN A LAMBIE C NTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PL13G INSPECTOR
CK S�
8 DEC 31 4 4.5 0 in