HomeMy Public PortalAbout10135 NADINE ST_Sewer__ ° APPLICATION FOR PERMIT
sae966°°MrSION OF BUMDMG AND SAFIW SEWER-SEWAGE DISPOSAL 1
Deportment of County Engineer
County of Los Angeles BUILDING 013
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JOHN A LAMBIE COUNTY ENGINEER ADDRESSKWIC
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS Sh ,�
LEGAL OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS jolu/ Zoe
NO OF BLDGS CI TEL
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO I GROUP I NAP
BUILDINGS
B PG
CONTRACTOR • �( 3
CONNECTION DATA
ADDRESS
Y o J STATION e�� (� DEPTH
CITY M 0 TEL NO MANHOLE REFERENCE PER
Q:3, STATE
REGISTRATION NO ' ❑ COUNTYLOWE
NO DESCRIPTIO OF WORK FEE / W
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO L GTH FRdm +�
PUBLIC SEWER @ $8 50 �fJ Y CURB P L M L TO_P L b
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $S 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO p p r�
EXTN CESSPOOL DRYWELL MANHOLE @ $200 CO IMP NO 4"ma. ` l J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER 0 $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 0 $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PEMT s 1 00
AUTHORIZATION TOTAL FSE Ll
�Q REIMBURSEMENT FEE
1 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 OF 19 CONNECT ADDITIONAL
OWNER OR O BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRES 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNT AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM E LEGAL OWN F THE ABOVE
DESCRIBED RESIDENTIAL PR TY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS)❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COU NGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Y O CASH t�
6 4 8 2 MAR 2? 4.,5 0 to