HomeMy Public PortalAbout5074 SERENO DR_Sewer__ w f,
aaKass If APPLICATION FOR PERMIT 1
DIV06N OF BUMDING AND SA= SEWER—SEWAGE DISPOSAL
Depmtrasnt of County Englnow
(Aunty GI " Angeles BUILDING -
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
25-0 7:2 444442.v® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY y
FOR APP CAN'! TO M IN CROSSSS ST
LEGAL OWNER
DESCRIPTION LOT NOAff
RAIL .nim A�
BLOCK TRAADORE83
0 B
G 1
812E OF LOT No
ITV OX LOT TEL NO
USE OF OISTAICT NO GROUP MAP
BUI
BK PG
LOING9
CONTRACTOR S N
ADDRESS 'Z 1 f 4- CONNECTION DATA
CITY - �` M B„ C TEL NO ' Y MANHOLE REFERENCE STATION DEPTH UPPER
REGISTRATION NO ��� 7 COUNTY ' LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ f 3 50 Y CURB P L Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD $3 00
OVERFLOW SEEPAGE PIT GRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE Q f 2 00 CO IMP NO JOB NO
ROUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PFJIMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL `
CHARGES
CONNECTION CHARGE FEE
OWNERS PE MR s 1 00
AUTEIORIZATION TOTAL FEE REIMBURSEMENT FEE "
0
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THI D OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEN SEPTIC TANK,SEEP,PITS)
ADORE! AND/OR DRAIXFIELD
I HEREBY ACKND LE GE THAT 1 HAVE READ IS PPLICATION CESSPOOL❑ ORYWELL❑
AND STATE THAT T BOVE IB CORRECT AND A TO COMPLY
WITH ALL COUNTY DINA.CES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRE SY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGAUSE D
CALIER
FORNIA OR THA AY THE LE OWNER OF THE ABOVE
DE9BRISED RESIDENT PROPERTYBACKFILL SEPTIC TANKS❑
SIGNATURE 9EEP PITS ❑ CESSPOOLS❑
OF FERMI
JOHN A LAMBIE OUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
Y G CASH
�{l p 7 9 9 6- P14Y g 4 200
to
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