HomeMy Public PortalAbout5519 SARA MAR LN_Sewer__ TS it 4�ioy 07.7-Fr
:a�;, rr APPLICATION FOR PERMIT 7
DIVISION OF RUII.DIIdG AND SAFETY SEWER—SEWAGE DISPOSAL 1
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Coanlp Enylnser
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Of
Las BUILDING
VIM JOUNTY ENGINB R ADDRESSCASSATTIN BUr-T Or BuiLzIms LOCALITYFOR O PILL IN "E`"�T
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LEGAL
DESCRIPTION LOT NO 1 OWNER a`fJA ej
BLOCKTRACT��'j('� /� fJLI'�/ MAIL
ADDRESSO OF
_SIZE OF LOT NOW ON LOTS CITY TEL NO
USE OF
BUILDINGS
4c1 DISTRICT NO GROUP YAP
CONTRACTOR 0. BK PG
ADDRESSO?6r. 6d CONN=ON DATA
CITY TEL NO STATION n O DEPTH dow
❑ STATE MANHOLE REFERENCE UPPER
NO ❑ COUNTY J J
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER 3 SO CURB P L M L TO P L
HOUSE SEWER CONNECTING TO
`1 PRIVATE DISPOSAL SYSTEM 1 OD
CONN ECT
ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 OD CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
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 ANO/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL ORYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
OvnEgS 1'E&MTS 1 00 COR NECTION CHARGE FEE
AUTHORMATION rTOTAL FEE 4e 5T REIMBURSEMENT FEE
IHAVE TRTHIS DATE To CONNECT THE OVECTED WDESCR BED ITH THE HEREIN NAMED
OWELLIOPP
ACTORNG APPROVALS DATE INSPECTOR 8SIG SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS SAY?I 19_ NEW HOUSE SEWER 6
OWNER OR , CONNECT ADDITIONAL
OWNERS ADENT� BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS-_ ANO/OR DRAIN FIELD
1 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
PLU"BING AND SEWERS SEWAGE REPAIR
DISPOHEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGI ERED AND/OR
EM
LICENSED AS REOUIRED BY LOS ANGELES COON AND ST E OF DISCONNECT PLUG AND
CALIFORNIA OR THA 1 AN
THE LEGAL XE F THB ABOVE ABANDON HOUSE SEWER
OESCRI BED RESIDE Al OPERTT ' 1 1 BACKFILL SE IC TANKS fI
SIGNATURE / PITS CESSPOO
OF PERMITTEE
WILLIAM J FOX.COUNTY ENGINEER VALIDATION R A.WOOD. CHIEF PLBG INSPECTOR
ICp5587n MAY 1 4 4.50
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