HomeMy Public PortalAbout9836 VAL ST_Sewer__ ae Kass 11 CC APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Englnser
County of LoM 'AngGlw BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTE) GRIFFIN SUPTOFBUILDINO LOCALITY
FOR APPLI ANT TO FILL. IN ca s GT
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO dF SLUGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO GROUP YAP
BUILDINGS I 1�1 BK
CONTRACTOR S
ADDRESS CONNEC ON DAYA
CITY EL NO / ION DEPTH
1 MANHOLE REFERENCE a.. UPPER
(Q ❑ STATE
REGISTRATION NO ❑ COUNTY
No DESCRIPTION OF WORK, FEE
HOUSE SEWER CONNECTING TO TYPE OF CTION LENGTH FROM
PUBLIC SEWER @ $S BO Y CUR P L Y L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® $S 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
EITN ,CESSPOOL DRYWELL MANHOLE S 2 00 CO IVP NO loo NO
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 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OVfRm'.S PmwT f 1 00
AUTHORIZATION SOSAL FEE d REIMBURSEMENT FEE _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS GATE INSPECTOR 991GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING RWELLING
TO THE PUBLIC SEWERHEW HOUSE SEWER -
SIGNE AY rJ _19CONNECT ADDITIONAL
OWNER OR - BUILDING OR WORK
OWM AGEI S EPTICTANK,SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY A LED THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYW ELL❑
ANO STATE THAT OVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY INANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEW S SEWAGE DISPOSAL SYSTEM
I HEREBY CERTI THAT Y PROPERLY REG13TERED AND/OR DISCONNECT PLUG AND
LICENSED A9 RED IRED BY LO NGELES COUNTY AND STATE OF
CALIFORNIA OR HtL 1 AN THE DEt.AL OWWNjB_kF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REST E PRO \ /( BACKFILL
PIT(s)
SEEP
SIGNATURE El CESSPOOLS❑
`'/
OF PERMITT
JOHN A LAMBIE, COUNTY ENGINEER _,VMMATION ROBERT A WOOD CHIEF PLBG INSPECTOR
/GI A M 0 GSH
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