HomeMy Public PortalAbout5118 SERENO DR_Sewer__i
J6A6420
cE RDRIaEv.6,78' APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT ND. GROUP AlMPRDCESRED Sl
BN PG
BUILDING
ADDRESS ti /' J. /
LOCALITY CONNECTION DATA
NEAREST STATION `. DEPrH �-
CROSS ST.
UPPER
- % MANHOLE REFERENCErLOWE
OWNER IF
TYPE OFC TI N LENGTH FROM
MAIL Y. URB P.L. M.L.TO P.L. 9i<Y
ADDRESS
P.C.NO.
CITY TEL.NO. CO.IMP.NO, JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO,
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTfl.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SI2E OF LOT NOW ON LOT HWY.OR ST,WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR - / MRRK
VALCHARGES
CITY TEL NO. CHARGE FEEaLCAENSE NO. j - CLABB } t ENT FEE Ola
NO. DES CPIIP710NO WORK FEE ROVALS DATE INSPECTORS SIGNATURETANK SEE P P
HOUSE SEWER CONNECTING TOPUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR SEWER >.
PITS AND/OR DRAINFIELD CONN EC
HOUSE SEWER CONNECTING TO WORKAL
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTICAN DRAINFIELD TANK,SEEP. ITIS) S
WORK TO HOUSE SEWER ANDICUC
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [I DRYWELLO CW
E% N..CESSPOOL.DRYWELL.MANHOLE
H
ALTER.REPAIR OR ABANDON HOUSEaEDN
REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEME DISPOSAL SYSTEM
NNECT PLUG AND
ON MOUSESEWER
LL SEPTIC TANKS U
OWNER'S PermitITISIO CESSPOOLS❑AUTHORIZATION TOTALFEE VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREITRACTOR TO CONNECT THE ABOVE OESCRIBEp E%IS + /
TO THE PUBLIC SEWER
SIGNEDTHIS DAYOF 19_
OWNEROR a • A R t /`
OWNERSAGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY f' 1
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF (. -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE '"t 1/
C[f°BID-S[
TBAB/[D APPLICATION FOR PERMIT
COVENT OF LOS XNGELES
GI SEWER—SEWAGE DISPOSAL
DEPAANNNIENNN OF COUNTY ENGIIiEEH
WELDING AND SAFETY DIVISION
BUdLAbEBIECom ED�QSST AO
WUATENSEy.
Sup i Of Bull Qq A (:Z.
_
LOCALITY
NEAREST
FOR APPLICANT TO FILL INLEGAL _Z;
DESCRIPTION L°TNO OWNER
`/ MAIL
[LOCK TRACT 5 �I ADDRESS
NO OF SLOGS _
EIZ[ OF LOT / NOW ON LOT oz CITY7Qff TR NO
USE OF
BUILDINGS DIST111CT NO ORO MAP PROCLSSeD BY
/J BK PO
CONTRACTOR V/�+
ADDRESS / CONNECHON ASA
CITY TEL STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
HO DESCRIPTION OF WORK F[[ TYPE of co IGH LENGTH P M y
NOOSE SEWER CONNECTING TO Y R• PL MI. TOP O
PUBLIC SEWER C [S 00 P C NO I.I
S PTIC TANK S LP °E PIT ON CO IMP NO JOB MO AT
HOUAN C CONNECINFIELTING
Q 1100°
HOUSE
SEWER POBAL SYSTEM
TO TRUNK PERMIT NO ROAD PERMIT NO .J
PRIVATE DIQPOEAL SYSTEM Q S300
CONNECT ADDITIONAL BLDG R AFFIDAVIT PYTO CA.I.I.T RECORD INSTR NO DAT[
WORK TO HOUSE SEWER O i OO
OVERFLOW SEEPAGE PIT GRAINFIELD Z
EITK C88SPoOL ORYWELL MANHOLE O iS OO HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOURS
SEWER OR DISPOSAL SYSTEM Y S 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTQ APPROVAL
OWNER'S PESN!!1' S z Do CHARD"
AUTHORIZATION TOTAL FEE 17 " CONNECTION CHARGE FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN AMEO CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED []USTINO OWELLINO RROVw*C DAT[ INML OR SSIONATVRt
TO THE PUBLIC SEWER A" ALS
SIGNED THIS--DAY O IE_
OWNEq OR NEW HOUSE SEWER
/
OWNERS AGENT
CONM[COR WORT NAL
ADDRESS BUILDING OR WORK
S,, IIC/OTANK SEEP PIT(S)
I HERESY ACKNOWLEDGE THAT 1 AVE READ THIS APPLICATION A .
NOR GRAINFIELD
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND R ALTER REPAIR SEWER OR
LICENSED AS REQUIRED B MOLES COUNTY AND STATE F SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I T l[GAL OWNER O AND INTE TO DISCONNECT PLUG AND
RESIOE IN TH[ A D RIS[D RESID[NTI RO STY ABANDON HOUSE S[W[R
SIOF TURE
PERM WKFILL SEPTIC TANKS ❑
OF P[RMITT SEEP PIT(S) ❑ CLSSPoOID
VCAMATION ROBERT A WOOD
M O CASE SUPERVISING MECHANICAL ENGINEER
L"3 2 6 9 Cd DEC 6 1 0 0 7.0 0" a
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