HomeMy Public PortalAbout5061 SERENO DR_Sewer__ 16 0 INSERTS
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1 TOA$4{�1D APPLICATION FOR PERMIT,
OF LOS ANG
COSEWER-SEWAGE DISPOSAL 1
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BUILDING AND SAFETY DPMON ARU'DD E'Nc
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DESCRIPTION LOT NO OWNER
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ADDRESS CONNECTION DATA
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REGISTRATION NO L U OlCOUNT MANHOLE REFFAKNCQ UPPER
xo DESCRIPTION OF WORK
FEE
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OVERFLOW SEEPAGEPIT ELRAINFIELD SS
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WORK TO♦f01/9EI� ENWA'L BLDG OR $1.02 tj O TRUNK PERMIT NO ROAD PERMIT NO 0.Q
T REPAIR OR ABANDON HOUSE $
I 00 STATE ENCROACHMENTDISPO AL SYSTEM apAl
PERMIT IA
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WASTE APPROVAL
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OWNEH•S PEow 2 00 CONNECTION CHARGE FEE
ADTHOEIZAIION TOTAL FEE REIYBUR9EMENT FEE
MED CON
TRACTORHAVE TO TO COXNECT THE ABOVE DESCRIBED T THIS DATE A CONTRACT WITH THE HEi1STNfl0ADWELON
LI NG APPROVALS DATE INSPECTOR 8SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CON XECT ADDITIONAL
OWNERS AGEMT BUI LOING OR WORK
ADDRESS SEPTIC TANK SEEP PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRTWELL
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLU YBIMG APD SEWERS SEWAGE DISP08AL SYSTEM
1 HEREBY CERTIF7 THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNT AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AY HE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE PROP T BACKFILLSE C TANKS
SIGNATURE SEEP PITS CESSPOOL!
OF PERYIT
mT �^{IAMATION ROBERT A WOOD
CL ■ o CAiM SUPERVISING MECHANICAL MNGINEM _
� '07427 � ft,r22 _ p 3.60
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