HomeMy Public PortalAbout5055 SERENO DR_Sewer__ saf�aes11SS _ - APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
D%mrftn nt of Co" Engtnwc
County of Los Angel" BUILDING J—
JOHN A LAMBIE COUNTY ENGINEER ADDRESS 5" S
CASSATTD GRIFFIN SUPTOFBUILDING LOCALITY
FOR APPLICANT TO FILL IN cao9RSS T
LEGAL
DESCRIPTION LOT ND OWNER )
BLOCK RACT02 41� s PAIL �..(�
�J ADDRESS)
10 OF
SIZE OF LOT 1_7 —�21j NOW ON LOTS C7 ` TEL NO K-1
USE OF A fco
RICT NO OROU�. YAP
USE OIN69 r Alb CONTRACTOR r / I O
ADDRESS �/ CONNECTION DATA -
r' N - DEPTH
CITY TEL NO G-t
OLE REPERENCE UPPER
REGISTRATION NO ❑ SLOWER
❑ c
NO DESCRIPTIO OF WORK FEEf
HOUSE SEWER CONNECTING TO YPE OF CommEC me LENGTH FROM.
PUBLIC SEWER @ S 3 50 URB
9 EPTIC TANK SEEPAGE PIT OR
,ITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P
EKTN CESSPOOL ORYWELL,MANHOLE ® $Z 00P NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG ORSTATE ENCROACHMENT
WORK TO HOUSE SEWER ® j 1 00 �V PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® j 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEE IIT 3 1 00
AUTHORIZATION TOTAL FEE
C REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SFy ER tr- NEW HOUSE SEWER
SIGNED THI A F 191)__ CONNECT ADDI71on AL
OWNER OR 1 BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID ENT, P PERTY BACKFILLSEPTIC TANKS
SIGNATURE SEEP PIT(B) ❑ CESSPOOLS❑
OF PERMITTEE J-14 11
JOHN A LAMBIff COUNTY ENGINEER VALIDATION ROBERT-A WOOD CHIEF PLBG INSPECTOR
cK ■ 0 CASH
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p 4 6 6 IN SEP 11 1, A 2.0-0
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:as 63Jlee APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Departo3ent of County Engineer _
County of Los Angeles auaDlxs
JOHN A LAMBIE COUNTY ENGINEER ADDRE!!
m CASSATTD GRIFFIN SIUPTOPBUILDING' LOCALITY / G
FOR APPLICANT TO FILL IN iR0,SST
LEGALS. S E. y� -3o OWNER
DESCRIPTION LOT NO
BLOCK TRACT ..I nn MAIL
A ADDRESS
y -
NO OF SLOGS
SIZE OF LOICO7l Q OW ON LOT ��� CITY TEL NO
USE DI 1
BUILDINGS DISTRICT NO GROUP YAP
�.r BK PO
CONTRACTOR
ADDRESS y 3 J CONNECTION DATA
CITY /y TEL NO[�, � 7 �� STATION DEPTH
MANHOLE REFERENCE _ UPPER
❑ BTATE LOWER
REGISTRATION NO 9�' q ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYft OF CONNECTION
PUBLIC SEWER S 3 SO LENGTH FROM
HOUSE SEWER CONNECTING TO T CURB P L Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PIT!AND/OR DRAINFIELD ® S300
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
E(TN CESSPOOL DRYWELL MANHOLE ® $Z DO CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM a $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM S 1 DO WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE. I
OWNER'S PEUCT s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEED
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED PXISTINg DWELLING
TO THE PUBLIC SEWER ''i! NEW HOUSE SEWER
SIGNED THIS DAY OF 19/ CONNECT ADDITIONAL
OWNER OR / BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTER AND/OR p]$CONNECT PLUG AND
LICE AS REQUIRED BY L ANGELES COUNTY AN STATE OF ABANDON HOUSE SEWER +'
CA ORNI OR THAT i A T LEGAL,\/J o KKR OF Xfi ABOVE
DES BED RESIDENTIAL P PERTY
BACKFILLSEEP PIT(gEPII CTASNKSO❑
BIG R ❑
OF +
JOHN A LA E.COUNTY ENGINEER 1VAMATION,, ROBERT A WOOD CHIEF PLBG INSPECTOR
CK ■ O
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