HomeMy Public PortalAbout10129 NADINE ST_Sewer__ 1
a&ESO APPLICATION FOR PERMIT 1
8$e SOS IS
OF BUHMING AND SAMY SEWER SEWAGE DISPOSAL
Deparbunt of County Engineer
County of Los Angeles FADDRESS
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JOHN A LAMBIE COUNTY ENGINEER CASSATT D GRIFFIN SUP T OF BUILDING
FOR APPLICANT TO FILL. IN CROSS sT
LEGAL Gl '7 OWNER
DESCRIPTION LOT NO d
MAIL
BLOCK TRACT g 1 ADDRESS /(
NO OF BLDGS CITY G TEL NO
SI2E OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO ( GROUP I MAP
Y/ K PG
CONTRACTOR (��N S
ADDRESS Z w �. g,,, CONNECTION DATA
STATION / a DEPTH ,
CITYA-1 0 C TEL NO OS
MANHOLE REFERENCE 1 PPER
a� ESTATE
REGISTRATION NO i 7/ ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 3 Y CURB M L TOP L
SEPTIC TANKSEEPAGE PIT OR
PITS AND/OR DRAINFIELD 0 $3 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
EXTN CESSPOOL DRYWELL MANHOLE $200
200 CO IMP NO 'merNe—
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR S E ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 P T No
ALTER REPAIR OR ABANDQN HOUSE INDUSTR
SEWER OR DISPOSAL SYSTEM ® $1 00WASTE APPROVA
M
CONN ON CHARGE FEE
OWNERS pEBf+IIT s 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 0
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPE;TOR SS1GN TURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 5
SIGNED THIS_ DAY F 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEN 9 SEPTICTANK SEEP PIT(S)
ADDRESS- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION r
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 P
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM o
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND vc
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA ORTHAT 1 THE LEGAL NER OF THE ABOVE
DESCRIBED RESIDENTIAL OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS)❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE rTY ENGINEERVALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
ICC-15
M o GISH
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