HomeMy Public PortalAbout10240 NADINE ST_Sewer__ °A°420 APPLICATION FOR PERMIT
DD ON OF BUILDING AND SAFI'1'Y SEWER—SEWAGE D I S POSA L 1
•j Department of County Engineer
County of Loa Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY 'J
4
FOR APPLICANT TO FILL IN "cRoss s
LEGAL
-DESCRIPTION LOT NO OWNER ,
NAIL
BLOCK TRACT ADDRESS
0 OF DGS
SIZE OF LO NOW 0 LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT N0 I 6R I BK MAPPJ
67
CONTRACTOR C.
Hick S Hldek s
CONNECTION DATA
ADDRESS 2 Penn �]pn l^
CITY l Mo u® TEL NO GI S--2SZ3 STATION J o DEPTH
149595 IC STATE MANHOLE REFERENCE /0UPPE
REGISTRATION NO [3 COUNTY
NO DESCRIPTION OF WORK FEE t
HOUSE SEWER CONNECTING TO TYPE OF CONNECTI LENGTH FROM
PUBLIC SEWER G $S 50 CURB P M L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $300 S00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE G $200 CO INP NO JOB NO
HOUSE SEWER CONNECTING TO I
PRIVATE DISPOSAL SYSTEM G $I Do TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER G $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM G $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER /
SIGNED THIS DAY OF X19 CONNECT ADDITIONAL 0/0p
OWNER OR ) d BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(S)
ADDRES AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 1
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
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 THE OVE
DESCRIBED RESIDENTIAL PRO ER BACKFILL SEPTIC TANKS❑ y
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS /-,
It:? /04
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER ,/'`VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK M 0 1 CASH
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