HomeMy Public PortalAbout5060 SERENO DR_Sewer__ CESDBIREV 6n9I APPLICATION•FOR PERMIT -
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SEWER-- SEWAGE DISPOSAL '
COUNTY OF LOS ANGELES BUILDING AND SAFETYI, "
FOR APPLICANT TO FILL IN olsrRCT No I DXDUF •, RA jCe5,5EDV
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CONNECTION DATA
NEAREST STATION' • ' DEPTH t '/` MANNOL[gQPERENCE _OWNER A TYPE OF CONNECTIONLENGTH FRTMAIL / 1 Y CURB PL MLTOPLPC NO
CO IMP NO JOB NO
CT
TEL.NO
LEGAL TRUNKPERMITNO ROADPERMITNO
DRSCRIPTION LOT NO
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
BLOCK TRACT
NO ON LOGS
OT
9QE OF LOT NOWONLOT HWY OR ST WIDBNINO
USE OF
BUM1DINGB STATE ENCROACHMENT /'D Z
PERMIT NO �O
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRESS
/
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CITY L� TEL NO CONNECTION CHARGE FEC
IIIICANSKNO Z GIC LASS REIMBURSENCNTFEE
NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTORSSIGNATURII
HOUSE S[WER CONNECTING TO
PUBLIC SEWER
SEPTIC TANKSE VAGE PET OR. NEW HOUSE SE W ER
P"AND/OR
DRAINFIELD CONNECT ADD?ZONAL
HOUSE SEWER CONNECTING TO BUILDING OR WGRK
PRIVATE DIBPOSAL SYSTEM
CONNSEPTICTANK SEEP PRI91
QAK T AOUSE OBLDG OR AND/OR DRAINFISLO-
86SE L WER �-• �' - -
OVERFLOW SEEPAGE PET DRAINFIELD CRSSPOOL ❑ ORYW[LL❑
EXTN CESSPOOLORVWELLMANHOLE
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SeW[R OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNSCT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS Ll - -�
OWNER'S
Permit S _._ SEEP PITISI❑ CESSPOOLS❑
AUTHORIZATION 'TOTAL FEE -- - OMEN
_,VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH TME HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHB PUBLIC SEWER ON $ 1 79.5A
9I' EDTHIS OAT OF 19[�
SN[RE AGHNT 1 I t Tt B B E AS 1 0
ADDREai V 2 B B 1 ° '
I HE BY IICKNOVVLEOGE T 1 HAVE RSAD THIS APPLICATION
AND STATE THAT TH! ABOVE I CORRECT AND AGRBB TO COMPLY S E B 1 O O
WITH ALL COUNTY ORDINANCES AND STATE LAWS REOU"nT
PWY ERRS CERTIFY THAT I AM PRIDPERLY REGISTERED ERWERf r� 3-78
E p
OR
LICENSED AS REQUIRED BY LOS ANGSLEE COUNTY AND STATE/OF 1 6 1 2 -7 8
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO RE
SIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY
SKINATURE - - - - - - - __--
OF PERMITTEE