HomeMy Public PortalAbout4909-4911-4913 SERENO DR_Sewer__ 1 — - 41650,INSEM .
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Taaeu° APPLICATION FOR NPER-R3E AGE DISPOSAL 1
��.Y OP LOS ANGELES '
DEPARTMENT OP CgUW" ENGMEEe
BTTB.DEIC; AND+� DIVISION BUILDING
N
m ADDRB46
N BAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER u'- ,
BLOCK TMCT 'PAIL _
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF
BUILDINGS Se DCT NOR�I BK YAP PROCESSED BY
CONTRACTOR
ADDRESS Z w M Ay� CONNECTION DATA
CIT O TEL NO / Y d {STATION DEPTH
ATE MANHOLE REFERENCE - UPPER
REGISTRATION NO 7 COUNT ♦ 170 LOWER
NO I DESCRIPTIO FOR FEE
POUSE SEWER CONNECTING TO
FUBLIC SEWER 9 SS 00
SEPTIC PE OF RECTION L8X0TX FROM
D�NK BEE PAGE PIT OR T RB P Y L TO P L
PITS AMD OR DRAI N FIELD S 00
OVERFLOW SEEPAGE PIT DRAINFIELD
E% N C 0 DRYWELL@ u DO
/ HOUSE SEWER CONNECTING TO P C NO
PRIVATE Y Y 100 D 0 31,010O TRUNKCO PPERYIT NO ROAD PERMIT NO a�
No JOB No
CONNECT AD ITIONAL BlDO OR
Co
WORK TO HO SE SEWER
A T R REPAIR OR ABANDON ROUSE STATE ENCROACNYENT p
SYSTI00 PERMIT NO O
INDUSTRIAL aE�pyf!+
WASTE APPROVAL
CHARGES
OWNF.E,S OD CONNECTION CHARGE FEE
ADTFIOAIZATION T FEE )(� REIYBU0.4EYENT PE4
TRACTOR I HAVE A TO CIONNECT THE ABOVE DESCRIBED EXS DATE A CONTRACT WITH THE ISTING NAMED
L U NO APPROVALS GATE INSPECT08591GNATUBE
TO THE PUBLIC SEWER
SIGNED THIS SAY OF +9_ NEW xousE SEWER -
OWNEROR AJC[ CONNECT ADDITIONAL
OW NETS AGENT BUILDING OR WORK
ADORES- ANO/OR DRAINFIELD'EPTIC TANK SEEP PITIS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS.APPLICATION.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS ALTEREWAGREPAIR
AL OR
EM
I HSEW
EREBY CERTIFY THAT 1 ■ PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A9 REQUIRED BY ANGELES CO TY AND STATE OF
CALIFORNIA OR TXAT 1 A XE LEGAL 0 N OF TXE AROYL ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P T BACKFILL SE IC TANKS
310gATURE SEEP PITS _CESBP00 LS
OF PERYITTE
m� MMATION ROBERT A WOOD
Q ■ o _ CA0
SUPERVISING MECHANICAL RNGINMR
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>CA�tD°' APPLICATION FOR PERMIT
CoF` ANGELES SEWER—SEWAGE DISPOSAL
DEPARTTbUMENTM CO
OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
WMALAbMZ Co.ty EG t ADDpett
WQ.i PAM A IENSPF. s.p f of SYildmp
LOCALITY
NEAREDT
FOR APPLICANT TO FML IN CRO!LEGAL
S ST
DESCRIPTION LOT NO OWNER
MAIL
BLOCK T.ef ADDRESS
Slze Of LOT N
NO OF SLOGS I _6 y�
OW ON LOT CITY TEL NO
USE OF
SUILOIN08 DISTRICT NO ROUE MAP OC[SBBD BY
BK PO
CONTRACTOR
ADDRESS CONNECTIC,N DA7
CITY TCL NO STwTION DEPTH
8TATE
REGISTRATION NO COUNTY MANHOLE REFER LWUPPER
LOWER
NO DESCRIPTION EC WORK Fee TYPE Of connettloN L¢LT PLOY
HOU[[SEWER CONNECTING TO Y CURB P L M L TO'L
PEPTIC iCW[R Y s5co
PITS AND/OR
0RAINFI D OR p C N
p1T8 ANO/OR DRAIXf1ELD Q {IO 00 CO IMP NO JOP NO
HOUSE PEW 6R CONNECTING TO
PRIVATE DISPOSAL SYSTEM m {i OD ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR AFFIDAVIT Yp W[R[IIl R[CORO INPTR NO OAT[
WORK TO HOOP!BlVICR O t5 DO
OVERFLOW SEEPAGE PIT GRAINFIELD
EKTN CESSPOOL DRYWELL MANHOLE 6 iB 00
ALTER REPAIR OR ABANDON MOUSE HWY OR PT WIDENING
°EWCR OR DISPOSAL SYSTEM 0 {i 00
STATE ENCROACHMENT
PERMIT NO
INOUBTRIAL
WASTE APPROVAL 1
OWNERS PERMIT a s o0 CHARGES
AUTHORIZATION TOTAL FEF. CONNECTION CH FEC
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBU MENT PEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR O SIGNATURE
SIGNED THIS DAY OF iB_ _
OWNEROR NEW HOUSE SEWER
OWNERP AGENT_ CONNECT ADDITIONAL ,�f `� r
BUILDING OR WORK J�( J f�
ADDRESS
SEPTIC TANK SCEP PIT(0) /
I
HEREBY ACKNOWLEDGE LEDGQ THAT 1 HAVE READ TNI° APPLICATION AND/OR GRAINFIELD / /
ANO 6TATE THAT THE
ABOVE I° CORRECT AND AOReE TD COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MING AND PEWER° C!S° OOL ❑ ER
❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ALTER REPAIR SEWER OR
LICENSED At REQUIRED BY LOS ANGLES COUN [TATE OF S[WAO[DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM TH! L O F AND INT[MO TO OIBCONN ECT PLUG AND
ptBID
Q IN T%! A R [ NTIAL PROPERTY ABANDON HOUSE SEWER
PI6NATV pQ V BAGNFILL SEPTI C TANKS ❑
OF PERMTTTE SIE. IT
(S) ❑ CBPSPOOLP
VALIDATION ROBERT A WOOD
CK M O cwtH SUPERVISING MECHANICAL ENGINEER
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