HomeMy Public PortalAbout5104-5104- 1/2 SERENO DR_Sewer__ S&a211CA APPLICATION'T.ORERMI 1
DIVISION OF BUMDBNG AND SAFETY SEWER—SEWAGE-DISPOSAL '
Department ut County Engineer
County of Lae Angeles / eUILDING q1A
WM J FOX. COUNTY ENGINRKR ADDRESSY CASSATT B GRIFFIN SUP T OF BUILDINGLoceunFOB CANT TO FILL IN NERROSS BT
LEGAL
DE6CRIPTIOM LOT NO OWNERA ace
BLOCK TRACT MAILADDRE88 NO OONI OT8CITY TEL NOUSE OFmI BUILDIMGS DISTRICT NO GROJI� BK
CONTRACTOR
ADDRESS5 I CONNECTION DATA
CITY A- TEL MO Q &'F' v STATION DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO 13 `P ❑ COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
No DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® S S SO _
"OUSE SEWER CONNECTING TO
PRIVATE DISPOSAL"STEM 1 00
CON ECT ADDITIONAL BLDG OR CO IMP NO JOB NO
WORN TO HOUSE SEWER 1 00 _
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 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELO 2 00 INDUSTRIAL
CESSPOOL.DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
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OvVNER'S p�T s I Do
AUTHORIZATION TOTAL PEE REIMBURSEMENT FEE
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I CTORTTO CONNECHIS TT TNTRDATE CHE BOVEWITH DESCRBED EXITHE STINGA DWELLIONG APPROVALS DATE INSPECTOR S SIGNATURE
HAVETO THE PUBLIC SEWER
SIGNED THISDAY OF, 2l 19- NEW HOUSE SEWER
OWNER OR ny •p'_.. I CONNECT ADDITIONAL %
OWNEfl9 AGE AYi171e 'F 0.M. L BUILDING OR WORK .
ADD_ ANDEPT/ORIC TO RAINFIELDBEEP PIT(8)
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 BEWARE REPAIR
DISPOHEWER R
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY _ BACKFILL SEP C TANK9❑
BEEF FITS CE59 POOLS
SIGNATURE
OF PERMITYE
WILLIAM J X3 COUNTY ENGINBBR VALIDATION
BY 3S7EnMILR 2 .4 .
JG) T
- DEPUTY
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III !AI DEPUTY DEPUTY