HomeMy Public PortalAbout5147 SERENO DR_Sewer__ 7
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0 APPLICATION FOR PERMIT
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YDAQON OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
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BUILDING
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CAGGATTD GRIMM, SUP-T Or 111U6 Ma LOCALITY
FOR APPLICANT TO FILL IN NEAREST
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DESCRIPTION LOT NO 1r / OWN E ��.GyE.F(,Gy</
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CT IPA S d i� �i��f3 ADDRESS Xcg1:l40,0e .!���
SIZE OF LOT
X I NOW ONBLOTLDGS CITY —' EL NO I
USE OF
BUILDINGS StL DISTRICT NO GROUP YAP
P = B PO
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO STATION �- DEPTH
REGISTRATION NO 2 S/ 7,4 ..r �UNr 'MANHOLE REFERENCE
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0
NO
DESCRIPTION OF WORK FEE /� TYp NECTION LENGTH FROM
( `PUBLIC SEWERECONNECTING TO ® 3 SO J Y /CUFF P L Y L TO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM too
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER too CO IMP NO law JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL•DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 1 CHARGES
OyNNER'$ $ 1 00
pEBZ� CONNECTION CHARGE FEE
AUMOBPLATION TOTAL FEE CTED WITH THE H REIN RAN Ep REIMBURSEMENT FEE
TRACTORTHIS
TO CONNECT THECONTRA
BOVE DESCRIBED �It BTING DWELL G APPROVALS DATE INSPECTOR 9SIGNATURE
TO THE PUBLIC SEWE
SIGNED THI AY OF Iy NEW HOUSE!EWER �p
OWNER ORCONNECT ADDITIONAL
OWNERS AGCMT BUILDING OR WORK
ADDRESS y� AND/IORTGRAINFANK IELDPIT(9)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL O
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 REPAIR
DISPOSALSYSTEM
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY HAC
aarCESSPOOLS i
SIGNATURE
OF PERMITTER
• - ' ' - " "
WILLIAM J.FOX CouNTY EN61Ni m VALIDATION R.A.WOOD, CNIGP FLOG INGPECTOR
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