HomeMy Public PortalAbout5208 SERENO DR_Sewer__ W .
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TeeeAEp APPLICATION FOR PERMIT
COUNTYDEPARTMENT
OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPAHTILgNi OF COUNTY ENGiNEEB
BUILDING AND SAFETY DIVISION euaDlNa
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LOCALITY !
NEAREST
FOR APPLICANT TO FILL IN cRoeP Br P�aab•
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TRACT AD.RMAILE8° �J/C
NO OF SLOOP
OFLOT OW ON LOT Cln TEL NO
fi
p DIQT"CT NO OROPNAP PROCEpBQD BY
eK P PDTOR ' t .� • D1 J M ' / Z (J0" V"
t CONNECTION DATA
eW . TEL NO BOO STATION 2'1.- /_O. DEPTH
REGISTRATION NO \ ❑ COUNTY MANHOLE REFERENCE T S'7!J D LYO'RWrCq
NO DESCRIP'T'ION OF RK FEE TYPO of co [CTION LENGTH PROM !
HOUSE SEWER CONNECTING TO Y R P L M L TO P L
PUBLIC SEWER d pp OO �-!J
B[PTIC TANK e[[PAO[PIT OR CO IMP NO I / / JOe NO
PITS AND/OR DRAINPI6LD Y {1000
HOUSE[EWER COMNECTINO TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 0 p300
CONNECT ADDITIONAL BLDG OR QO AFFIDAVIT vyr[t u[[Wrt RECORD INS" NO WT[
WORK TO-HOUSE SEWER O $O 00 1
OVERFLOW SEEPAGE PIT DRAINFI[LD
LSTN CESSPOOL DRYWELL MANHOLE Y Sp 00
ALTER flEPAIR OR ABANDON HOUE6 HWT OR 6T WIDENING
SEWER OR DISPOSAL SYSTEM Q SS 00 STATE ENCROACHMENT _
PERMIT NO
INDUSTRIAL
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�}�.}�a WASTE APPROVAL
OWNERS PEBI[DT f 2 00 CHARGES
AUTHORIZATION TOTAL FE 0= CONNECTION CHARGE P[E
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT P[[
TRACTOR TO CONNECT THE ASOVQ DESCRIBED E%IpTIMG OW[LLIND
TO THE PUBLIC SEWER //,, A"ROVAIS E INBPECTORII SIGNATURE
SIGNED THIS AY OF Tep,�
OWNER OR NEW HOUSE SEWER
OWNERS AO[NT CONNECT ADDITIONAL
ADDRE86 BUILDING OR WORK
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS LIGATION SEPTIC TANK S[[P PIT 161
AND STATE THAT THE ABOVE 13 CORRECT AND e[ TO COMPLY AND/OR DRAINFI[LD
ALL
WITH ALL COUNTY
ORD
INANCEB AND STATE "LAWWS R[ODUITINO
PLUMBING AND SQWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED O/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED MY LOS ANOL[B COUNn TATE OF SEWAGE DISPOSAL SYSTEM
GLI FOflNIA Ofl THAT 1 AM THE LEGAL OW ER OP A AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AS V D I.RI[ XSID TI L P06PER7Y ABANDON HOUSE SEWER
SIGNATURE pACKPILL S[Pf IC TAX
OF PERMITTEE ❑
SEEP PITIe) ❑ C[[EPOOLS
(�Ck//,,OALMATION A ROBERT A WOOD
M D" CASH SUPERVISING MECHANICAL ENGINEER
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