HomeMy Public PortalAbout9613 VAL ST_Sewer__ i
a&K CCs 11 CB APPLICATION FOR PERMIT 1
DMSION OF BUMNG AND SAFM SEWER—SEWAGE DISPOSAL
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JOHN A LAMBIE COUNTY ENGINEER ADDRESS
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FOR APPLICANT SO FILL IN NCROSS BT !/
LEGAL
DESCRIPTION LOT NO OWNERe-jo
BLOCK TRACT ADORES9 I ••j J /•
NO OF SLOGS CIT �� P 101 EL NO
SIZE OF LOT -YZNOW ON LOT
USE DI DISTRICT YO GROUP YAP
USK OF GS
CONTRACTOR
S BK PG
ADDRESS/ c s L/� AO CONWIMON DATA
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CIT TEL NO , (` STATION DEPTH
MANHOLE REFERENCE UPPER
9/b'TATE OI
REGISTRATION NO ❑ COUNT
NO DESCRIPTION OF WORK FEE ZO �j
HOUSE SEWER CONNECTING TO Y TYPE OF CUR,
Cox N EGf1O(7 L J YEL GTO P L Y J 0
PUBLIC SEWER @ S S BO
SEPTIC TANK,SEEPAGE PIT OR
PITS AMD/OR DRAINFI ELD (R $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P G NO
EKTN CESSPOOL DRYWELL,YANHOLE ® S 2 00 CO IMP NO JOB N I
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 tE
PERMITXO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 1WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
Ovnmis PEEMFT 00
AUTHOAIZATION TOTAL FEF REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPAOVALS GATE INSPECTOR SSIG NAT URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED TRI DAY OF19�� CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AG X ) SEPTIC TANK SEEP PIT(S)
ADDRESSFIAZII AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I y VE READ IS APPLICATION CESSPOOL❑ DRYWELL❑
ANO STATE THAT THE ABOVE IS CORRECT AND GREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR pISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE LEGAL OW R OF THE ABOVE
DESCRIBED RESIDENTIAL P ERT BACKFILL SEPTIC TAN ❑ /
SIGNATURE SEEP PIT(S) ❑ CESSPOOLSKS G
OF PERYITEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLSG INSPECTOR
IN
DXo03� JAN 9 4 450
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