HomeMy Public PortalAbout5164 SERENO DR_Sewer__ TEA 6120 ` CESOS - 9/T3 ` ''
t APPLICATI N FORE PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 54--g
FOR APPLICANT TO FILL INLEGAL
[A.
CRIrt1aN LOT NO Z�
CK TRACT . 3 6 ADDRESS3 ✓
NO OF SLOGS
OF Lor Now ON Lor {.per TEL NO
OF
DINGS GROUP[ MAP CE55ED BY
Sit P5
CONTRACTOR
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ADDRESS �00„�r' CONNECifO1N' DATA
CITY �'J lyr[4L O 171 415-3-A RATION �j GID[1TN /
T( OL/ �I k/ GLA.. - L� OC/t0 XXX///���'���5 L WER
NSE NO
MANHOLE REFS [NCC
DESCRIPTION OF WORK FEE TYPE or N I LENGTH FROM S-
HOUSE$MEN CONNECTING TO '1 Y NP r L TOP
Wl
PUBLIC SEER 0 $T 00 V
SEPTIC TANK 5EEPAGE PIT ON 2 7 P C NO
PITS AND/OR DRAIMFICLD � {1000
CO IMP NO ✓ UOe NO
NOUS[S[W[R CONNECTING TO TRUNK PERMIT NO ROAD PSAMIT NO
PRIVATE DISPOSAL SYSTEM d [600
CON NECT ADD ITIONAL SLOG OR wIFIOAVIT RYRI• W[R[RT RECORD ... NO DATE
WORK TO NOUS(SEWER O 5300
OVERFLOW SEEPAGE PIT GRAINFIELD
(YTN CESSPOOL ORYWELL 0 5500
ALTER REPAIR OR ASAMOOM HOUSEHWY ORST WIDENING 8 rf Ale
5[WER OR DISPOSAL SYSTEM 0 5100 .TAT[ENCROACHMENT
MANHOLE O {T 00 PERMIT NO C.T
INDUSTRIAL W
CL.
WASTE APPROVAL Tn
Z
POWNF.Fi'3 PER11107 • ] 00 CHARGES
AV}T�IMCIFI LA 10N TOTAL FEE O 0 0 CONNECTION CHANGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE N[R[IN NAMED CON REIMBURSEMENT F[E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ACC1<OVAL�
TO THE PUBLIC SEWER DATE INp[ TO IONATUR[
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGE N!
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT 1 HAVE BEAD THIS AFFLIC ATION SER IC TANK SEEP PIT(S) -
AND/OR GRAINFIELD
AND STATE THAT THE ABOVE I. CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING ❑
PLUMBING AND S[W[RS CESSPOOL ❑ DRYWCLL -
1 HCREDY CERTIFY THAT I AM PN P RLY REGISTERED AND/OR ALTER REPAIR SEW(ROR
LIC(NS[O A. REOUIR[p BY LOS ANGLES COUMr AND STAT[ 01 SEWAGE DISPOSAL SYSTEM
CALIIOIINIA OR THAT I AM PLO L[OAL OWNER OI AND INTEND TO DISCO
PLUG AND
REBID[ IN THE ASOV O[STHE L L OWNER RG RTY
ABANDON HOUSE SEWER
SIGNATURE
OP PCIMTTT[[ /TBACKFILL 6C ICT ❑
L19PACK PIT 161 L.
VALIDATIO c( M o cwex
'1 I
2 8 2�P1AY 21 1 0 D 1 0.0 0 Abo
70A 812D - CEDOB - 9/73 APPLICATION FOR PERK
COUNTY OF LOB ANGELES SEWER-SEWAGE DISPOSjAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD1Ha /
ADDRESS
LOCALITY
MGR[ST
FOR APPLICANT TO FILL IN CRoaS fT
LEGAL F
RIPTION LOT NO -L OWNN
// MAIL
K TRACT N V AODREee
NO OF BLOCS
OF LOT NOW ON LOT CI I TEL NO �Z'
USE
OF
DISTRICT NO CROUP NAP OCl SSlD BY
INGS
A■RK Pp
RACTON �O 1 /r ` /
ADOREBB US CONNECTION DATA
CITYTEL NO 6 3s33 RATION 6PTN
LICENSE NO �� � LIPPER
STATE � O Aff L'C '1l MANHOLE REFERENCE ' G2-d OWER
No DESCRIPT N OF WORK F[6 ryPC CON [ 10 T! �J L[naTN FROM y
HOUSE SEWER CONNECTING TO Y Y L TO P L L?�
PUBLIC SEWER O $700
SEPTIC TANK f LPAOC PIT ON P C NO
PITS ANO/OR GRAINFIELD C •1000 CO IMP NO J JOB MO
HOUSE SEWER CONNLCTING TO
PR NAT:EWER
SYSTEM 0200 TRUNK PERMIT NO ROAD P[11MfT NO
C
CONNECT ADDITIONAL[LDO OR AFFIDAVIT RUTTE TYT[TRf RECORDMSTR NO DAT
I [ y
WORK TO HOUSEyp[SEWER 0 p 00 1
OVERFLOW SEEPAGE PIT GRAINFIELD I I Q
EITN CESSPOOL DRYW[LL O •900 NWY OR ST WIDENING a•/
ALTER REPAIR O ABANDON HOUSEC.
SEWER OR DISPOSAL SYSTEM 0 Si 00 STAR ENCROACHMENT
MANHOLE 0 $7 00 PERMIT NO CWT
IN TRIAL L
{�ISi�p� WART[APPROVAL DO
TT�.O[}TTI�TEI�L ASF f 00 CHARGES
A V IH0FnATI0 —� CONNECTION CHARGE F[[
1 HAVE AT THIN DAT[ A CONTRACT WITH THU H[KIN NAMED CON REIMBURS[YEMT FEE
TRACTOR TO CONNECT THE ABOVE GLBCRID[D EXISTING DWELLING �1 Tip *p
TO THE PU SLIC SEWER APPROVALS DATE INSP[CTO BBIONATUR[
SIGNED THIS DAY OF 19_
OWNER OR NEW HWS[SEWER
OWNERS AGE MT
CONNECT ADDITIONAL
ADDRESS BUILDING ONR WORKWORK
f[ITICTANK •ILP PIT(B)
I
HEREBY ACKNOWLEDGE LEDGE THAT 1 HAVE READ THIS A PLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS R[ ULATINa
FLU MINING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED NO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED •Y LOS ANGLES COUNTY AND B T[ OF SEWAGE DISPOSAL SYSTEM
CAl1IORMlA OR THAT I AM THE l[GAL OWNER OF AND INT NO TO DISCOMNtCT PLUG wMD
R6SID[ IN TN[ ABOV OLSCRIS[D R[•IOEMY L PRO
ABANDON HOUSE SEWER
SIONATUR[ / f //� T
OI PEf MRT[[ l/`�' CKFILLSETINKS
P (:ISAITIB) C
POO..
VALID• O CXM 0 CASH
�Z
2 8 1nMAY 21 1 1 0 3 0.0 0c�AZk