HomeMy Public PortalAbout10153 NADINE ST_Sewer__ IIIaxaD APPLICATION FOR PERMIT 1
8.seeD1MSION OF MUDDIG AND SAFETY SEWER SEWAGE DISPOSAL
Depadmisuf of Counfip Engfnees
County of Los Aageler BU'LD SG
JOHN A LAMBIE COUNTY ENGINEERIIF
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL. IN CROSS ST
LEGAL O� OWNER
DESCRIPTION LOT NO
�� O ADDRESS f t
MAIL
BLOCK TRACT
NOOF BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE
BUILDINGS DISTRICT NO I GROUP MAP
PG
CONTRACTOR
_.t- I <t F,
ADDRESS - CONNECTION DATA
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STATION DEPTH
CITY TEL NO Q 9 O S MANHOLE REFERENCE
NATE
REGISTRATION NO , OWER
❑ COUNTY �
NO DESCRIPTION C WORK FEE TYPE OF CONNECTIO LENGTH FROM °�
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ S S SO Jr
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE 0 S 2 00 CO IMP NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM (0'f $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ Sl 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERBUT f 11 o0
AUTHORMATION I TOTAL FEE Yl 5110
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 THIS DAY OF ]9 CONNECT ADDITIONAL
OOWNER OR
WNERS AGENT fl_ BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I 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
I 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 1 A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P PERTY BACKFILL SEPTIC TANKII❑
SIGNATURE SEEP PIT(S)❑ CESSPOOLS[3 `
OF PERMITTE
JOHN A LAMBIE C�PNTY ENGINEER JMATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Y O CA86
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