HomeMy Public PortalAbout10143 NADINE ST_Sewer__ r
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s e B seAPPLICATION FOR PERMIT 1
DMSION OF BURDING AND SAFM SEWER--SEWAGIt DISPOSAL
Depcoft ent of County Engineer
County of Los Angeles FAADDR
DING
JOHN A LAMBIE COUNTY ENGINEER ESS
® CASSATT O GRIFFIN SUP T OF BUILDING LITY
FOR APPLICANT TO FILL. IN cS ST
LEGALOWNER ✓
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO I GROUP I MAP
SJ
BK PG
CONTRACTOR N ._`LIT"
ADDRESS 02 Z CONNECTION DATA
S STATION DEPTH
CITY TEL NO
_ MANHOLE REFERENCE 4t TATE UPPER
REGISTRATION NO / ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM yy
HOUSE SEWER CONNECTING TO Y CURB P M L TO P L p� !
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO JOB NO
EXTN CESSPOOL DRYWELL MANHOLE 0 $2 00
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 @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ 4100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMT a 1 00
AUTHORIZATION TOTAL FEE <fi REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
ol
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -1TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY O 19 CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK
/�
OWNERS AGENTx— 4220 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
1 HEREBY CERTIFY THAT 1 AN 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 OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PR RTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS)❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE CdU ENGINEER VALIDATION ROBERT A WOOD CHIEF FL13G INSPECTOR
C Y O "ON -
4,
2 .9 6 4'r OCT 4 4 4.502