HomeMy Public PortalAbout5025 SERENO DR_Sewer__ C['OBUBD B'
TSABAPPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DIS SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O F)
IOC! A LA�pU�RIEvvCounty Evmp�v �r A...
WILLIAM A JEMU , Sup 1 of Buil�q
LOCALITY
NEA REST
FOR APPLICANT TO FILL I1 CRORR ST
pEACRIPTION LOTNO OWNER
MAIL
[LOCK ff��^fTRACT / /�� ADOR J
SIZE OF LOT/S� S�IIOW ON LOTS CI TEL NO J
ueE or
BUILDINGSwla4WDISTRIRMO GROUP MAP PROCCS DeY
OK PG /
CONTRA RO S,08
=EBB CONNECTION DATA
PI ION DEPTH / /
ITY T[L NO ,0
REGISTRATION NO O -z' Te COUNTY MANHOLE REFERENCE
No DESCRIPTION OF WORK FE!
TVP O ton TNF /
HOUSE SEWER CONNECTING TO U P L TO P L
PUBLIC SEWER d [p 00
f[PTIC TANK S EPAO!PIT OR `,I L NO
PITS AND/OR DRAINPICLO Q sl000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT
PRIVATE DISPOSAL SYSTEM ip GO
CONNECT ADDITIONAL SLOG OR AFFIDAVIT uE WaRaxi RECORD IMBTR NO DATA
WORK TO HOUSE SEWER 0 S]00
OVERFLOW SEEPAGE PIT GRAINFIELD
E.TTM CESSPOOL RY tL MANEGE!O SS OO
ALTER R PAIR A X N MOUES HWY ORGY WIDE NO
R SP A 6M i3 GO
STATE OR C CNT
O PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT f
CHARGES
CONNECTION CHARGE PE[
AUTHORIZATION TOTAL FEE , (I
A It
I HAVE AT THIS DAT[ A CONTRACT WI y R THE HEREIN NAMED CON R[IMBURS[MENT FEE
TRACTOR TO CONKER E ABOVE O[! D 1 .
TO THE PUBLIC BE APPROVAL4 I DATE IMQPICTOR Q SIGNATURE
SIGNED THIS AY A t
OWNER OR NEW HOUSE B[WER
OWNERS AO[NT 7z,1 S CONNECT ADDITIONAL
ADp RQ86 BUILDING OR WORK
BHPTIC TANK SEEP PIT(B)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AMD/OR GRAINFIELD
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYVJELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMO/OR ALTER REPAIR SEWER OR
LIG[NS[p A6 P[OUIRIO Y LOS ANOL[f COUNTY AND BTATC OF SEWAGE DISPOSAL BYBT[M
.ALIIO.NIA OR THAT I THE LEGAL
OWNER OF A INTEND TO OISCONNHCT PLUG AND
RtSIDC IM TH6 ASOV [SERI R[SID[HTIAL P [RTY ApANDOX HOUSE SEWER
SIGNATURE C ❑
OF PERMRT![ BACKFILL B[PTIC TANNi
BQ[P FITISI ❑ CIASPOOLS
VALMAT'IO ROBERT A WOOD
CK M O DASH SUPERVISING MECHANICAL ENGINEER
8980ZZ �,ar1911 D 2500
CESOSB Ba
TeseuD APPLICATION FOR PERMI
COUNTY of LOS ANGELES SEWER—SEWAGE DISP L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F.—
DING a r
]DNN A LAMB E COYCry. LB wt GBWIIJ.IAM A. IERBEN SOP f O� EMBd1OpLITY
EST
FOR CANT TO FILL Di ° °TOl9CRIPTIONLOT XBLOCK TRACT 8 V O
OF BL OS
SIZE OF LOT OW ON LOT CITY TEL NO
NE OF
SUI LOING ISTRICT NO GROUP MAP rROC61 EY
(J/ SK PG
CONTRACTOR T �O V
Aooflee CONNECTION DATA
C L NO
/O DEPTH /
T!
REGISTRATION NO D �� ❑ COYIITY MANNOLQ REFERENCE [
NO K DESCRIPTION F WO RQE TYP O NNBMON TO FROM I
HOUSE SEWER CONNECTING TO T P L
PUBLIC SEWER d ES OO C NO
SQPTICTANK SEEPAGEPIT OR CO IMP NO / JOB NO
PITSAND/OR DRAINFIELD d EI000
HOUSE SEWER CONNECTING TO . TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM Y $S DO
CONNECT ADDITIONAL[LOO OR AFFIDAVIT RMTI° IIIIRINT RECORD IMSTR NO DATE
WORK TO HOUSE SEWER C SS GO
OVERFLOW SEEPAGE PIT GRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE O SSW
ALTER REPAIR O ABANDON HOUSE HWY OR WIDENING
SEWER OR DISPOSAL SYSTEM C 93M STAT OAC [ ' A
PERM +/
INDUSTR AL
WASTE APPROVAL
CHARD"
OWNER'S PERMIT $ i 00
AUTHORIZATION TOTAL FEE Z
O CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WI THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONN[ E ABOVE D[ I I II�I}}��TT�Tpp II�p
TO THE PUBLIC BE AMOVALS AT6 / INSPECTOR OM'TYRE
SIGNED THIS 4d D OR
OWNER OR NEW HOUSE SEWER / I/1 /
OW N[RB AG[HT CONNECT ADDITIONAL I I
BUILDING OR WORK
AODflQ96 SEPTIC TANK BE" PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR GRAINFIELD
AND STAT! THAT THE ABOVE IS CORRECT AND AG REM TO COMPLY
WITH ALL COUNTY ORDINAXCEH AND STATE LAWS REGULATING
PLUMBING AND 9EWERS [ALTI!R
SPOOL ❑ DRYWELL ❑
I H[RKBY CERTIFY TH T 1 AM PROPERLY REGISTERED AND/OR REPAIR 9EWEROR
LICENSED A9 REQUIRE Y LOS ANGLES COUNTY AND STAT[ OFAGE DIBPOSALSYSTEM
CALIFORNIA OR THAT M THE GAL OWNER OF A NTEND TOCOMM[CT PLUG AND
RC61D[ IN TNH ASDES,.RNDONHOUSEB[W[R
SIONATUfl[ K FILL SEPTIC TANKS ❑
OP PITIS) ❑ CESSPOOLS
VALROBERT A WOOD
M a
CN y o cA9H— SUPERVISING MECHANICAL ENGINEER
VdD3 9 5 0 '-'119 1 b 0 7.00-
VVv