HomeMy Public PortalAbout5117-5119 SERENO DR_Sewer__ 70A6440oKAPPLICATION FOR PERMIT _
• DIVISION OF BUHMMG AND SAFETY SEWEREWAGE DISPOSAL
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WM J.FOX.COUNTY ENGINBLE ADDRESS
CMIGATT D GRIFFIN, SU T OF DUIL JHQ LOCALITY
FOR APPLICANT TO MIIN N ARM
DESCRIPTION LOT NO 4-X%'AL 0 bg OWNER
BLOCK TRACT MAIL
ADDRESS
SIZE OF LOT /(�O NO OF BLOCS TEL p0
NOW ON LOT CIT
USE OF eW
BUILDINGS DIBK PG
NO GROUP MAP
CONTRACTO 0 _ U
AG 11
ADDRESS I C //b s7- CONMIMON DATA
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CIT ZX TEL NO-7:::---V9 STATIONDEPTX
MANHOLE E R NC /
REGISTRATION NO - LOWER
NO DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE VECTION LENGTH FROM
PUBLIC SEWER ® f 4 90 U M L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR POS
NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOS NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AHD/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK,SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 00 WASTE APPROVAL
CESSPOOL DRYWELL
SPECIAL CONDITIONS ONLY 200 CHARGES
FI��T CONNECTION CHARGE FEE
OWNEg'$ f 1 00
AUTHOBMTION TOTAL FEEly REIMBURSEMENT FEE
I HAVE DATEN MED CON
TRATORTHIS TO CONNE TO THE AABOVE DESCRIBEDWITH THE EY ESTING DWELLING APPROVALS DATE INSF CTOR 6SIGNATURE
TO THE PUBLIC SEWER v .-7
SIGNED THIS. DAY OF l 19-9 NEW HOUSE SEWER 5 I S
NER OR / CONNECT ADDITIONALOR
(�
OWRERS AGENT c/V BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRE44 AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLO
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 SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNT AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEG W=ER OF ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY
^"'W^• 9E IC TANKS
SEEP PITS CESSPOOLS
SIGNATURE
OF PERMIT
WILLIAM J O OUNTY ENGINERRR VALIDATION R A.WOOD, CHIEF PLOG INMFKCTGR
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5 5 8 3 APR,3 0 4 5.5 0 m