HomeMy Public PortalAbout4922 SERENO DR_Sewer__ Te,AeARD .�• APPLICATION FOR PERMIT
waaw;;�MSION OF BUMDUM AND SAFETY SEWER-SEWAGE DISPOSAL 1
DermW2ant of County Englneae
County of Low Angalaw BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m 10
CASSATT D GRIFFIN SUP T OF BUILDINQ LOCALITY
FOR APPLI TO FILL IN CROSS BY /
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT i ADDRESS
OF BLOBS CITY TEL MO
SIZE OF LOT NOW ON LOT
111
USE OF
OU ILD OISTR N GROUP YAP
BK PG
CONTRACTOR
ADDREss CONNECTION DATA
STATION ' DEPTH /
CITY TEL NO43&94
YAN ROLE REFERENCE UPPER
GY r ATE
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION F RK FEE TYPE OF CYTON LEL BTH FAOY
ROUSE SEWER CONNECTING TO CURB M L TOP L
PUBLIC SEWER S 3 40
SEPTIC TANK SEEPAGE PITON
PITS AMD/OR DRAINFIELD @ S 3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTL CESSPOOL DRYWELL MANHOLE ® $2 00 CO IMP NO lOB NO
ROUSE SEWER CONNECTING TO
PRIMATE DISPOSAL SYSTEM ® Sim TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® $122 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE ,
OWNER'S PEU41T s t o
AUTHOPMTION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN'RIMED CON- APPROVALS DATE INSPECTOR SS NATURE
TRACTOR TO CON EC THE ABOVE DES IBED II IN DWELLI
TO THE PUBLIC NEW HOUSE SEWER
SIGNED THI AY OF 19 CONNECT ADDITIONAL
OWNER OR —� �' BUILDING OR WORK
OWNERS AGENT l r` +, I /�Y % PTIC TANK,SEEP,PIT(3)
A0DRE5 1 R DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ'THI PLICAT 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 EREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LIARVITTIE
A8 REQUIRED LOS ANGELES COUNTY AND STATE OF ABA DON HOUSE SEWER
CIA 0 THAT I HE GAL OW OF TN ROVE
do
DD IOELTIAL OP If A IT 4 I CESSPO O Gr t,
sl l �WVV f
JOHN A L.AMBIE.COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLEIG INarecroR
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