HomeMy Public PortalAbout5112 1/2 SERENO DR_Sewer__ moo m2a ee APPLICATION FOR PERMIT
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SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGMM
RUD.DIIQG AND SAFETY DMNON BUILDING I
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No {D DESCRIPTION OF WORK FEE
PUBLIC 6�ERCONNECTING TO 0S 00 '
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGT TROY
PITS AND OR DRAINFIELO S T CURB P L Y L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
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HOUSE SEVER CON NEC TING TO P BAD
VA 01 P C L 1 CO IMP NO 4 JOB NO
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TRUNK PERMIT NO ROAD PERMIT NO 2
WORK TO HOUSE SEWER 1 '
A T REPAIR OR ABANDON HOUSE ISTATE ENCROACHMENT
SYSTEMPERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
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AUTHORIZATION To7AL FEEa REIY B URlEYEXT FEE
TRACTOR TO HAVE AT HIS DATE A CONTRACT WITH THE CONNECT THE ABOVE DESCRIBED EIRE LLMED IN 6 APPHOV DATE IN9PEROR 3SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS_ DAY OF 9— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT n C"rBUILDING OR WORK
ADDRESS SEPTIC TANK LEEP PIT(S)
ARD OR DMI NPIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ TCATION
AND STATE THAT THE ABOVE IS CORRECT AND ACOMPLY CESSPOOL ❑ DRYWELLWITX ALL COUNTY ORDINANCES AND !TATE LALAYINGPLUMBING AND SEWERSALTER REPAIR SEWER OR
I HEREBY CERTIFY THAT I AY PROPERLY REGAND/OR SEWAGE 019POSAL SYSTEM
LICEMBED AS REQUIRED BY LOS ANGELES OUNTATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 TRE LE NERABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P PER'RBACKFILLSE C TANKSSIGNATURE 9E PIT 9 CESSPOO
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Malee 25 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELM SEWER—SEWAGE DISPOSAL i
DEPARTMENT OF COUNTY ENGUMM %
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BLOCK TRACT MAIL
S ADDRESS t N .Q f`
NO OF SLUGS
SIZE OF LOT NOW ON LOT CITY
USE OF
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CONTRACTOR
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CITY TEL 106 STATION
REGISTRATION NO COUNn MANHOLE REFERENCE ! UOIVER
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PUBLIC SEWER ® 39 00 TYPE OF CONNECTION L@NGTN FRO■
SEPTIC TANSEEPAGE PIT OR T CURB P L Y L TO P
PITS ANK DID
DRAINFIELD 0 SS 00
OVERFLOSEEPAGE PIT DRAINFIELD
N CESSPOOL.DRTW 00 P C MO
OUSE SEWER CONNECTING TO
IMADISPOSALA N 00 CO IMP XO JOB N
CONNECT ADDITION%L BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WOR K TO ROUSE SEWER Z '
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STATE ENCROACHMENT
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INDUSTRIAL
WAIITE APPROVAL
Sa C O 0CHARGESOWNS" PEHMIY fCONNECTION CHARGE FEEAUMOEIZATION TOTAL FEE O J REIMBURSEMENT FEEI HAVE AT MED CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTS DATE A CONTRACT WITH THE HEREIN LING APPROVALS ATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWERSIGNED THIa DAY OF _ NEW HOUSE SEWER
OWNER OR eWCONNECT ADDITIONAL
OWNERS AGENT /� BUILDING OR WORK
ADDRESS SEPTICTANK SEEP PIT(0)
AND/OR GRAINFIELD IHEREBY ACKNOWLEDGE THAT I HAVE READ THISTIONANO STATE THAT THE ABOVE IS CORRECT AND AGRMPLY CESSPOOL ❑ DRYWELLWITH ALL COUNTY ORDINANCES AND STATE LAWSTING ALTER REPAIR SEWER ORPLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT 1 AM PROPERLY REGISD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOII ANGELES UNn E OFCALIFORNIA OR THAT I THE LEGA MER OBOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA OPERTYBACKFILL SE C TANKS
SIGNATURE SEEP PIT 9 CESSPO r3 I
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ALIDATION BERT A WOOD
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