HomeMy Public PortalAbout10152 NADINE ST_Sewer__ •
TEp1E CITY
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CE80CZ/70
76A 8420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
BUILDING
10152 E. Nadine St•
JOHN A LAMBIE COUNTY ENGINEER
City
COLEMAN W JENKINS SUPT OF BUILDINGe e
R PLC NT TO FILL IN Ardan Dr.
(PRINT OR TYPE ONLY) y�
DESCRIPTION LOT NO OWNER Milton BeAyeMAIL
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BLOCK, TRACT ADDRESS 20 B3.re o o 1�
NO OF BLDG&
SIZE OF LOT NOW ON LOT CITY Aroadl.aTEL NO
USE OF Des DISTRICTNO GROUP CLASS MAP OCE SEED BY
BUILDINGS .L3
7�A �/y-s B K P 6
CONTRACTOR S uare Deal Sewera �� /
ADDRESS 2 Y CO IECTION DATA
CITY El Monte TEL NO4WI,.-2020 5 DEPTH
STATIO A/
STATE 128870 GLASS C-42 LIC MANHOLE REFERENCB ,4 , fes- LOWER
LICENSE NO �/V
NO l DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
1 HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER ® SB 00 7 00
SEPTIC TANK SEEPAGE PIT OR C NO
JOB NO
PITS AND/OR DRAINFIELD ! $1000 CO IMP NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEMEM $3 00 TRUNK PERMIT NO ROAD PERMIT NO � CL.
B
CONNECT ADDITIONAL BLDG OR AFFIDAVIT-n[IlilMtMT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300 V
OVERFLOW SEEPAGE PIT DRAINFIELD cc
EXTN CESSPOOL DRYWELL MANHOLE SB 00 HWY OR ST WIDENING O
ALTERREPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® $3 00 STATE ENCROACHMENT W
PERMIT NO O.
INDUSTRIAL t0
��+p WASTE APPROVAL Z
OWNER
YYNERS PERMR E OO CHARGES
AUTHORIZATION I TOTAL FEE 10 CONNECTION CHARGE FEE
I RHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE*Q
TACTOR TO C04NECT THE ABOVE DESCRIBED EXISTING DWELLING f�Lf1f1MOVAis7
TO THE PUBLIC SEWER D TE 1 ECTOR S IGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OW AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(8)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT IAM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIA ROP--TY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS [30
F PERMTTTEE SEEP PITIS) ❑ CEBSPOOLB
ATION JACK R ALLEN
CK M I CASH SUPERVISING MECHANICAL ENGINEER
J60 -9 3 S 9.-J APR 101 J 0 1 0.0 0,. q