HomeMy Public PortalAbout4968 SERENO DR_Sewer__ Sal s11BB• APPLICATION FOR PERMIT 1
DIVMON OF BUMDMG AND SAFETY SEWER-SEWAGE DISPOSAL
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JOHN A L.AMBIE COUNTY ENGINEER ADDRESS
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NEAREST APLICANT TO FIN CROSS
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BLOCK TRACT /%,
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ADDRESS
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NO OF BLDGS CITY L NO
SIZE OF LOT NOW ON LOT
USE O
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BILDINGS DISTRICT NO GROUP YAP
f _z- BK F
CONTRACTOR f
ADDRESS Q CONNECTION DATA/
CI TEL NO STATION DEPTH
MANHOLE REFERENCE UP
❑ STATE
REGISTR TION NO �' b a0 ❑ COUNTY
No DESCRIPTION OF WORK FEE TYPE OFC ECTION LENGTH FE
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HOUSE SEWER CONNECTING TO T R P L Y L TO P LOU
PUBLICSEWEft co 9 3 fi0
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® S 300
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL,DRYWELL MANHOLE 0 92 00 CO IPP NO JOB NO
HOUSE SEWER CONNECTING TO /
PRIVATE DISPOSAL SYSTEM ® S 100 TRUNK PERMIT NO ROAD PERMIT NO �O
CON N ECT ADDITIONAL SLOG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® 91 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 1 00 /
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I NAVE AT THIS DATE A CONTRACT WITH THE HEREIN APED CON APPROVALS DATE IX ECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DES BED EAISTING DWELLING
TO THE PUBLIC 5��Jy'E1/�7 NEW HOUSE SEWER -
SIGNED THIS_Zy —D F CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(S)
ADORERS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ URYWELL❑
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 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLU6 AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AY THE L AL OWNER OF THE ABOVE
DESCRIBED RESIDENT PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERM ITTEE
JOHN A L.AMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
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