HomeMy Public PortalAbout5072 SERENO DR_Sewer__ Ghee APPLICATION- FOR PERMIT 1
DMSION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Couinly of A,
BUILDING
WM J FOX.Couw"ENGINEER ADDRESS O
! CASSATT O GRIFFIN,QU or B)un.DIma LOCALITY C
FOR APPLICANT TO FILL IN NEAREST
OSS ST
LEGAL
DESCRIPTION LOT SO OWNER
BLOCK TTRRACT011 MAIL
ADDRESS
SIZE OF LOT
� NOW OF ONBLDG
LOTS CITY Ole TEL NO / D
USE OF
BUILDINGS Aftaawd.. DISTRICT NO GROUP YAP
BK IRS
CONTRACTOR I
ADDRESS S CONNECTION DATA
CITY TEL NOA,0 G fvQ 0, STATION 0 DEPTH
❑ STATE MANHOLE REFERENCE #4 4ruppn�
REGISTRATION NO .� Q ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE NECT[ON LENGTH
PUBLIC SEWER ® S S SO Y CURB P L Y LEN
TOFROND
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR Pc
NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
FEHMTI CONNECTION CHARGE FEE
0mrNmrs E 1 00
AUTHORIZATION TOTAL FEE d REIMBURSEMENT FEE
IHAVETRACTORT
TTOS CONNECT THEA BOVEDATE CONTRCTEDWDESCR BED EXISTINGA DWELLING ITH THE HEREIN NMED CON APPROVALS DATE IM8 ECTOR SSIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEWER ..w
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT �� BUILDING OR WORK
SEPTIC TANK SEEP PIT($)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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 I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPT C TANKS❑
/ SEEP PITS CESSPOOLS
SIGNATURE
OF PERMITTEE
WIWAM I F X.COUNTY ENGINEER VALIDATION R A WOOD,CHIEr PLOD INSPECTOR
LAC08455—� X20 4 550 In