HomeMy Public PortalAbout5512 SARA MAR LN_Sewer__ °•°ARD APPLICATION FOR PERMIT
D VIMON OF BUWUIG AND SAFETY SEWER—SEWAGE DISPOSAL
D"awbnsa! of Co=ty Englnsu
County of Los Angs4s EDILOIgG
' JOHN A LAMBIE COUNTY ENGINEER ADDRE99
® CASSATTD GRIFFIN SUPTOPBUILDING LOCALITY
FO APP C YO FILL IN cADse�BT
LEGAL S OWNER
DElC T10 LO N
MAIL
BLO R ACT AO E39
NO OF BLDGS
SIZE OF LOT NOW ON LOT TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP ,YAP
BK P6
CONTRACTOR
ADORES CONNECTION DATA
STATION G J/U DEPTH A
TEL NO
MANHOLE REFERENCE UPPER
STATE
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE OF CON NECTIOq�� LEN GTN FROM
PUBLIC SEWER Q S 3 SO T CURB /P C) Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTH CESSPOOL,DRYWELL,MANHOLE ® S Z 00 CO IMP NO JOB NO
HOUSE SEWER CONNEtt ING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® 31 00 PERMIT NO
ALTER REPAIR OR ABANDONTRIAL HOUSE
SEWER OR DISPOSAL SYSTEM S 1 00 INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE '
OWNER'S PEDM S 1 00
AUTHORIZATION TOTAL PEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM- "PBOVALS DATE INSP ttOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC SEWER NEW HOUSE SEWER L
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYW ELL❑
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 I SEWAGE DISPOSAL SYSTEM -
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR D ISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGAL OWNER THE ABOVE
DESCRIBED REST NT ROPE BEEP FPIT(3EPO CESSPO O❑
SIGNATURE
OF PERMITTEE
JOHN A LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
GK ■ a F -
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