HomeMy Public PortalAbout5060-5062 1/2 SERENO DR_Sewer__ aaaD APPLICATION FOR PERMIT .S,
CD r'or
eEIMMON OF BUMMIG AND SAFEfY SEWER-SEWAGE DISPOSAL 1
Dsvertatuant of County Engines:
County of Los Angels■ BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTD GRIFFIN SUP T OF BUILDINO LOCALITY
FR C O FILL CROSSS si
LEGAL !Rl
DESCRIPTION 7 OWNER if
MAIL
BLOCK CT AODRE93
NO OF BLDG!
SIZE OF LOT NOX ON LOT CITY TEL NO
BUILDINGS
OF
BUIUSELDIN69 DISTRICT NO GROUP YAP
BR PG
CONTRACTOR
ADORE: CONNECTION DATA
�� E REFERENCE // DEPTH
CITY ^�
TEL NO MANNA;
w6 L STATE
REGISTRATION NO )4V9�./ ❑ COUNTY
NO DESCRIPTION OF WORK FEE - - -i
HOUSE SEWER CONNECTING TOTYPE 0 ION LENGTH FR Y
PUBLIC SEWER (of 441"0 Y CURB P L M L T° P L1, _
�—
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD a 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD / �J P C NO
EKTN CESSPOOL DRYWELL MANHOLE S Z00 CO IMP NO J 7 SOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 100 TRUNK PERMIT NO ROAD PER NO
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 100 PERMIT MO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 00
AUMOR=TION TOTAL PEE va
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEBEIN NAMED CON. APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNER! AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
IH
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/00. DISCONNECT PLUG AND
LICENSED AS RF,OUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGAHOUSE SEWER
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF E ABOVE
DESCRIBED RESIDENTIAL PROPEPT BACKFILL SEPTIC TANKS❑
SIGNATURE BEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
GN L& O � XT241oA 5.00