HomeMy Public PortalAbout10134 NADINE ST_Sewer__ °ABAPPLICATION FOR PERMIT
Sts EGGS
1I iMON OF BUMMIG AND SAFELY SEWER—SEWAGE DISPOSAL 1
Department of =s=ow
County of LOB Aageles FADDRESS
LDING O
JOHN A LAMBIE COUNTY ENGINEER
CASSATT D GRIFFIN SUP T OF BUILDING ALITY
AREFOR APPLICANT TO FILL IN "cREr �DQ•G7s.�
LEGALOWNER `
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
NO O BL CITY C.) TEL 2
SIZE OF LOT NOW ON LOTT
USE OF DISTRICT NO GROUP I MAP
BUILDINGS � � BK PG
CONTRACTOR `3
ADDRESS 2 V If CONNECTION DATA
CITY TEL NO Ya STATION —A O�O DEPTH
S
` MANHOLE REFERENCE
REGISTRATION NO /�S` ❑ COUNTY 4TATEa D LOWER
NO DESCRIPTION OF CONNECTING TO WORK FEE
HOUSE SEWER CONNECTYPE OF CONNECTION LENGTH FROM
�O �G oC
PUBLIC SEWER @ $3 50 Y CURB L M L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 0 $9 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE ® $2 00 CO IMP NO Joe-NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 $1 00 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 PERMIT s 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THI DAY DR 19 CONNECT ADDITIONAL
OWNER OR ENT BUILDING OR WORK
OWNERS AGSEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNO LEDGE THAT I 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
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 NER OF THE ABOVE
DESCRIBED RESIDENTIAL P ERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITT
JOHN A LAMBIE CO,WITENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
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8 68A DEC 3 i 4 4.50 91