HomeMy Public PortalAbout4958 SERENO DR_Sewer__ 6AGCO APPLICATION FOR PER T
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOS L
DEPALT14M OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F
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WMALAMIE Coun Ea[inw R[ae
WILLIAM A LENSEN Bop i of Bwl v
ALITY
MQBT
FOR APPLICANT TO RILL IN S ST
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DESCRIPTION LOT NO NER
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[LOCK TRACT RE63
NO OF ¢EDDY
SIZE OR LOT NOW ON LOT CITY TEL NO
US[ OF
BUILDINGS DISTRICT NO GROUP MAR PROCESS
BK RO
CONTRACTOR _
ADDREIY ,3 CONNECTION DATA
CITY 8L N ( �� STATION -:46 DEPTH
6TA [ UPKR
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
ND DESCRIPTION F WORK F TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y 4V30 I P LTO P L a
PUBLIC SEWER O LE 00
SEPTIC TANK SEEPAGE PIT OR C
PITA AND/OR GRAINFIELD 0 SIO OO JOB O OV
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO K
PRIVATE DISPOSAL SYSTEM a S]OO 1 O
CONNECT ADDITION AL SLI OR D AFFIDA IT RMYu 4[(x[xT R[CO11ffDD INSTR O OAT[
WORK TO HO USE BLWER 0 [30o /O / �/ E 1 •
OVERFLOW SEEPAGE PIT GRAINFIELD T IVY
..TN C...POOL ORYWELL MANHOLE SE OO a
N
ALTER REPAIR OR ABANDON OUSE HWY ORST WIDENING
SEWER OR DISPOSAL SYSTEM d [300 STAT[ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z 00 CHANCES
AUTHORIZATION I TOTAL FE D CONNECTION CHARGE PEE
I HAVE AT THI¢ DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF IB_
OWNER OR NEW HOUSE SEWER
OW NCRS AGENT
CONNECT ADDITIONAL /1
ADDRESS BUILDING OR WORK N
SEPTIC TANK BEEP PITIS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ TXIB APPLICATION AND/OR GRAINFIELD
AND STATE THAT TX[ ABOVE IB CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYW[LL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS RED INFO BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALI FORMIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIOL IN THE A C OCB RI BED REST EMTI PROPERT ABANDON HOUSE SEWER
SIGNATURE
OF PERM ITTL BACRP S[IT11C TANKS ❑
LEEP PIT
(e) lJ Cs-24
VALIDATION ROBE T A WOOD
cK M O 1 CASH SUPERVISING MECHANICAL ENGINEER
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