HomeMy Public PortalAbout5023 SERENO DR_Sewer__ a e aA003 it Be APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFEfY SEWER—SEWAGE DISPOSAL
Depmrbnout of County Engineer
County of Los Augelw BUN.DING 3'D� SE rmmo J37 JOHN A LJAMBIE COUNTY ENGINEER ADDRESS '7CASSATTD GRIFFIN SUPTOPoUILDINO LOCALITY (� G / CqFOR APPLICANT TO FILL IN RCROSS ST f ,E 7crNrLEGAL 4y / OF -L / �/ OS• .(/ Oi4NSONDEBCRIP'f10N LOTNO OWNERPAILBLOCK _ 5;nwT Am. .3 ADDRESS 0NO OF BL CITY TEL NO -�
SIZE OF LOT , NOW ON LOT
DBE DI ld E L r S
U31 O NG9 DISTRICT NO GROUP YAP
BK PG
CONTRACTOR _
ADDRESS 1�7£
' CONNECTION DATA
SAME
CITY TEL NO STATION DEPTH
MANHOLE REFERENCE - UPPER
❑ STATE LOWER
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 SO Y CURB P L Y L TDP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 33 00
OVERFLOW SEEPAGE PIT DRAINFIELOP C XO
EKTN CESSPOOL DRYWELL MANHOLE 0 $200 CO IVP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 ,TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG ORSTATE ENCROACHYE!
WORK TO HOUSE SEWER ® 11 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE •O INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 5, DO WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE _
OWNER'S PERMIT 3 1 00
AUTHORIZATION TOTAL FEE
REIMBURSEMENT FEE
00
I HAVE AT THIS DATE A CONTRACT WITH THE HEREI! APED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE�S CRIBED EXISTING DWELLING t
TO THE PUBLIC SEWER ����{iiiPPrrrr� NEW HOUSE SEWER
SIGNED THI DA OF 19CONNECT ADDITIONAL
OWNER OR // BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKN LEDGE THAT I VE READ THIS APPLICATION CESSPOOL❑ ORYWELL❑
AND STATE THAT HE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR 019C0N NECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATI ROBERT A WOOD CHIEF PLGIG INSPECTOR
GA D; MAY 3 4 3.0 0 ID