HomeMy Public PortalAbout5449 SARA MAR LN_Sewer__ 1 9
as K60alyAPPLICATION FOR PERMIT 1
aaDMISION OF BUIMING AND SAFETY SEWER—SEWAGE DISPOSAL
DepoQfineot of Cmmtt Engl¢ser
Conatp of Los Angels BUILDING ♦♦� .��
WM J FOX COUNTY ENOINKCR ADDRESS fA
CASIeATT O-6RIFPIN. eUr T or luILDINa LOCALITY �LE
nLe
FOR APPLICANT TO FILL IN NEAREST
CROSS 9T Gb-G/LV
LEGAL O Y � 7
DESCRIPTION LOT NO _ J /]� �A' OWNER
BLOCK TRACT LJ,finl Lal /f(��p MAIL �7 _ Q
ADDRESS �] C /Q�JK/Q
NO OF BLOGS
SIZE OF LOT NOW ON LOT CITY 'Z' ( TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP YAP
SK PO
CONTgACTO
AODRus CONNECTION DATA
TEL N 77 STATION si'yLO� DEPTH
❑ STATE MANHOLE REFERENCE
REGI STRATTON NO ❑ COUNTY UPPER _ LGEWI
TYPE OF CONNECTION LENGTH FROM
No DESCRIPTION OF WORK FEE r n- PW- Y L\TO P L
HOUSE SEWER CONNECTING TO '✓�T� 1 (/�
PUBLIC SEWER ® S ¢50 �_
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 Is
CONNECT ADDITIONAL BLDG OR CO IMP NO (�
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EKISTING
,SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2 DO INDUSTRIAL
CESSPOOL-DRYWELL - --- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 GO CHARGES
OWNER'S PERMIT s ) o0
CONNECTION CHARGE FEE
•�I
AMORMATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AM
TRACTORTTOS DATE CONNECT WITH THE
DESCRIBED NAMED
DWELL ✓crB
G AOVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER /
SIGNED THIS AY OF � lyyJ' NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SND/OR
TANK SEEP PIT($)
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
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRE BY LO! ANGELES COUNTY AND STATE OF
CALIFORNIA O T AN TH LE GA
OF TN ABOVE ABANDON HOUSE SEWER
-
DElCRIBED RES L PROPIA BACKFILL S C TANKS❑
SE¢P PIT
f CESSPOOLS
SIGNATURE
Of..
WILLIAMJ FO C NTY I21B7SR - VALIDATION
eY 1 '&5 4 1 0n JLL 7 4- 450 In
'
DEPUTY DEPUTY
y DEPUTY
'BY By
lD DEPUTY �� DEPUTY