HomeMy Public PortalAbout5105 SERENO DR_Sewer__ *a&m6 312 B. APPLICATION FOR PERMIT 1
DMSION OF RUMEIING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of CountyEnginNY
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WM J FOX, COUNTY ENGINEER ABDRE63 �`�O J !//
CAmmATT O GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPUCCANT TO FNEAREST
ESCRP / EAeT
DCI �' C Sd
OWNER F� £•
BLOCK TRACT �•S. – MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT
NOW ON LOT CITY TEL NO
USE OF
BUILDINGS ' DISTRICT NO I �GRO� YAP.
CONTRACTOR ./Atiw/ BK PG
ADDRESS CONNECTION DATA
CITY If
TEL NO I N DEPTH
REGISTRATION NO /2- 6 p3 r • COUNTY �/V TATE �S" YAN PPE EFEREN CE LOWER
TYPE OF C INECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y cUR P L M L TO P L
HOUSE SEWER CONNECTING TO ) �D
PUBLIC SEWER ® S 3 50 .l _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
_ WORK TO HOUSE SEWER 1 00 _
ALTER OR REPAIR EXISTING I
!EWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE EMCROACXYHNT
AND/OR DISPOSAL SYSTEM 1 00 _PERMIT NO
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 200 INDUSTRIAL
CESSPOOL-DRYWELL —— WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGE!
` CONNECTION CHARGE FEE
OWNER'S PERMIT s I o0
AUTHORIZATION TOTAL FEE 4 r REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED =STING DWELLING APPROVALS DATE IN ECTOR S SIGNATURE
TO THE PUBLIC SEWER
— �Y NEW HOUSE SEWER19
SIGNED THI DAY O lE.`3_
IFOR CONNECT ADDITIONAL
AGENT ^�I /� �• BUILDING OR WORK
ADDRESS RIS LD //A4A --d gQg 1 SEPTAND/OR TANK SIELO EEP PIT(SI
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR pISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND $TATE OF
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS I (�
a BEEP PITS CESSPOOLS - SS Q
SIGNATURE
OF.PERM ITTEE
WILLIAM J. FOX.COUNTY ENaINEm VALIDATION
eY
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