HomeMy Public PortalAbout10157 NADINE ST_Sewer__ r
s:°
'e SI19S ' APPLICATION FOR PERMIT
DIVISION OF BURDMG AND SAFETY SEWER—SEWAGE DISPOSAL 1
D%xmtmmt of Cauaty Engluare
Comity of Lpa Angeles BUILDING �
JOHN A LAMBIE COUNTY ENGINEER ADDRESS s
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY /
FOR APPLICANT TO FILL IN cnoRss sT
LEGAL
DESCRIPTION LOT NO ~ d / OWNER dot
NAIL
BLOCK TRAC ADDRESS
p �/� NO OF BLCITY TEL N
SIZE OF LOT 6/ V vv NOW ON LOTT
USE OFormi,9z
DISTRICT NO I ROUP I NAP
BUILDINGS
r BK PG
CONTRACTOR i.f
ADDRESS ✓CONNECTION DATA
CITY NO STATION ` s DEPTH
MANHOLE RE RE CEUPPER
RE6ISTRATIO NO STATE LOWER
Z ❑ COUNTY
NO DESCRIPTION OF WORK FEEooRTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $350
OUSE SEWER CONNECTING TO Y CURB P L M L TOP L
SEPTIC TANK SEEPAGE PIT OR
PLT$AND/OR DRAINFIELD ® $300
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE® $2 00 CO IMP NO JOB NO
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 ® $1 0o WASTE APPROVAL p
CHARGES'%<
CONNECTION CHARGE FEE
OWNERS PE DW a 1 00
AUTHORIZATION I TOTAL FEE /11 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON APPROVALS DATE INSPECTOR SSIGNAT RE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ( P
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIDAY OF 19 CONNECT ADDITIONAL
I
OWNER OR �)� � BUILDING OR WORK
OWNERS AGENT ter
�/1�w SEPTIC TANK SEEP PIT(S)
ADORES g AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE 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 1 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 AM THE LEGAL OWNER OF TH7AB E
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S)❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY ENMAER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK It 0 Ia 3 :19 ZR MAR 20 4 450
t