HomeMy Public PortalAbout5522 SARA MAR LN_Sewer__ 9
•&9 APPLICATION FOR PERMIT 1
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OF B=ING AND SAFM SEWER—SEWAGE DISPOSAL
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Cc" Of LDS A°gelw BUILDING -
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
CASSATTD GRIFFIN SUPTOPSUILDING LOCALITY
FOR APP CAVY TT 91110'
IN CHOSRS ST
LEDAL / OWNE V
DESCRIPTION OT NO
BLOCK TRACT MAIL
AO ES!
NO OF SLOGS T NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDI KGS DISTRICT NO GROUP ■AP
BK PG
CONTRACTOR
ADDRESSS.-/.
CONNECnON DATA
L NO /• • STATION e4 , 00
4 710 - DEPTH
MANHOLE REFERENCE APPER
REGIlTMTION NO . 'STATE LOWER
,3 ❑ COUNTY
NO OUSE
NOF WORK FEE TYPE OF CONRECTIOX LENGTH FROM /
NOOSE BEWER CONNECTING TO S CURB P L Y L TOP L
PUBLIC SEWER ® $3 SO
BEPTIC TANK,SEEPAGE PIT OR
ITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IVP NO JOB NNO
EXTN ,CESSPOOL ORYWELL MANHOLE® S 2 DO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 !1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
'OWNERS PIDI14I1' S 7 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSP CTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 51
A.
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AMD/OR DRAINFIELD
I 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
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIREO BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM T LEGAL OWMER OF THE-ABOVE
DESCRIBED RES[ NTI ROP SEEPFILL PIT SEP❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE JL
JOHN A LAMBIE. COUNTY ENGINEER VIUMATIO � ROBERT A WOOD CHIEF PLEIG INSPECTOR
ti (,'L1 0 3 3In Am 6 4 4.5 0 ID