HomeMy Public PortalAbout5116 C & D SERENO DR_Sewer__ 0'0A/
76A 5Qo� CE/be - 9/T3 APPLICAT N FOR PE IT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL d.0
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIRG `
A OD.
LOCALITY
FOR APPLICANT TO FILL IN CRUOiT
LEGAL
DESCRIPTION LOT No own[R �.$
MAIL
BLOCK TRACT ADDRESS
NO OF BLDOS
SIZE OF LOT NOW ON LOT CITY TR NO
us[ OF
S '
USK OFG DISTRICTN JOROUP MAP ppOG [D BY
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CONTRACTOR E /
ADMEN /� y CONNECnOm DATA
CITY r MJJ'`/
TEL NO a STATION 1 DEPTH
STATE
HO J I� CLASS LIC MAXHOL[RtPERCNC[ RRSR
LOWER
NO DESCRIPTION OF WORK FE[ OFCONN[CTION LEMGTNI
HOUSE{EWER CONN[CTI NO TO Y CURB P L M L T L
PUBLIC{[Wu 0 /] 00
SEPTIC TANK SEEPAGE PIT OR P D
PITS ANO/OR GRAINFIELD O $To Do Co IMP NO
HOUSE SEWER CONNLCTINO TO TRUNK PERMIT IN pAD PERMIT n0
PRIVATE DISPOSAL SYSTEM 0 Ll GO
CONNECT ADDITION AL SLOG OR A
FFIDAVIT EYTTT T T[T [CORD INSTR NO OAT[
WORK TO HOUSE SEWER 0 SSoo
OVERFLOW SEEPAGE PIT GRAINFIELD O
[[TN CESSPOOL DRYWELL d Law G7
ALTER REPAIR OR ABANDON HOUSE OR" WIDLNIN
SEWER OR DISPOSAL SYSTEM 0 S3 OO
C 6NCROACHM[ ,0
MANHOLE O $T 00 MIT NO �
STRIAL 1
T[APPROVAL (/)
CHARGES =
OWNER'S PERMIT s AUTHORIZATION TOTAL FEE / lip NECTION CHARGE FEE
1 HAV[ AT THIS DATE A CONTRACT WITH THE HEREIN MAM[DM BUR{EMENT F[[
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINO DW[TO THE PUBLIC SKWER AMOVALS DAT[ INSPECTOR S SIONAT R[
SIGNED TN18
OWNER OROA/ CONNEW HOUSECTA DCW[fl
OW MCN AaERT = -
LUILDIN ADDITIONAL
ADDRESS BUILDING OR WORK
BCPTIC TA NK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR MAINFI[LD
AND STAT[ THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND S ERS CESSPOOL ❑ DRYWELL ❑
I HEREBY IFY THAT I AM PROPERLY REGISTERED AND/ ALTER REPAIR SEWEROR
LICENSED A P[OVIRED BY
LOS ANGLES COON A D STAT[ 01 SEWAGE DISPOSAL SYR
CALIFdINI O T 1 AM THE L[O WNL F A D INT[ TO DISCONNECT PLUG AND
RESIDE IN [ A V DESCRIBES CN AL P PERTY ABANDON HOUSE SEWER
SIOF PER BACKFILL SEPTIC TANKS ❑
OF P[SM [
SEP PIT 161 ❑ C[e{POOL{
VALIDATION CK M O CASH
2 4 1PAN 28 10 D 1 4.0 0 �