HomeMy Public PortalAbout5212 SERENO DR_Sewer__ ss2-42-
anAiastins APPLICATION FOR PERMIT 1
DIVISION OF BIDI.MG AND SAFM SEWER—SEWAGE DISPOSAL
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COUWty of LOe Angeleat BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CABSATTD GRIFFIN 9UPTOFBUILDING LOCALITY C.i
FLIEGA
PLICANT TO FILL IN 00"ST
OWNERJ �!1 ,ADDRESS/z �-JOW ON LOTS CITY L. TEL NO rc� p S5BUILDISTRICT NO GROUP MAP
ABK P6
CONTRACTOR KI �-
ADDRESS S T CONNECTION DATA
, STATION DEPTH
CITY TEL NOj_ (9 („oI e00 MANHOLE REFERENCE UPPER
❑ STATE LOWER
REGISTRATION NOJ30!2,0 ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLICSEWER @ S Y CURB P L M L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® f 3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL DRYWELL MANHOLE ® f Z 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® $I 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM S 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE' _
OWNER'S PERMIT s 00
AUTHORIZATION TOTAL FEE RE MBURSEM ENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED UISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR ��1 BUILDING OR WORK 1 /7
OWNERS AGENT II SEPTICTANK SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE'READ THIS APPLICA N CESSPOOL❑ DRYWELL❑
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITIS) ❑ CESSPOOLS❑
OF PERMITTEE '
JOHN A LAMBIE COUNTY ENGINEER VALIDATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
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