HomeMy Public PortalAbout5068 SERENO DR_Sewer__ w
9a m963 I1 BB APPLICATION FOR PERMIT 1
DIVISION OF 13UWDiG AND SA= SEWER—SEWAGE DISPOSAL
Depoxfineaf of Co=tr Engines
1 Coantr of Lee Angel" BUILD "
JOHN A LAMBIE.COUNTY ENGINEER ADDRESS
® CASSATT 0 GRIFFIN SUP T DP BUILDING LOC11
REARM
ALITY
FOR LICAPIT TO FIMIN tR0 !T p.
LEGAL OWNER
DElGRIPT,Ofl LOT N
_ _ 3 NAI
BLOCK TRACT ADORES!
/ 'I NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
US
E OF DISTRICT NO ROUP YAP
BUILDING!
�. BR P6
CONTRACTOR
ADDRESS 31 11v .5 CONNECTION DATA
CITY TEL NO b4 y Go 9TAT IOR DEPTH �-
YAXHOLE REFE ENCE UPP
❑ STATE
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
I HOUSE SEWER CONNECTING TOTYPE OF TION LENGTH FROM
Y
PUBLIC SEWER @ S 3 SO R P L Y L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $3 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C RO
EKTN CESSPOOL DRYWELL MANHOLE ® S S 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 3100 TRUNK PERMIT NO ROAD PERU IT NO []7
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDONHOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEEbIIr f 1 00
REIMBURSEMENT FEE
AUTHORIZATION Toru 1EE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- "PROVAIS DATE INS PELT NATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWE NEW HOUSE SEWER �, 1
SIGNED THI AT OF 19y...,IL CONNECT ADDITIONAL
OWNER OR I BUILDING OR WORK
OWNERS AGE T SEPTIC TANK SEEP PIT(S)
ADORES ANO/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAV flEAO TIMS1.17CAN CESSPOOL❑ DRYW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULA IMG ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANDSTATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDER L ROPERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PITS) ❑ CIS POO 9
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Y 0 GA
'ACO 4 9 3 8 DEC 9, 4 4.5 0 n