HomeMy Public PortalAbout9072 ACASO DR_Sewer_0 ` C
76A 8a2D - CE808 - 9/73 APPLICATI FOR RMIT
COUNTY OF LOS ANGELES SEWER—SE AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNE-A:EST
9 ,072.r A C A S L (? S
PM 12 1- ' G', !,
FOR APPLICANT TO FILL IN S)Z let N D
LEGAL ' Z TtF BACK
DESCRIPTION LOT NO g il D � r OWNER �I.�I •
MAIL
BLOCK TRACT �p" L' 3 ADDRESS `7672- AC_A S a .�
..II NO OF BLD4S g� k4--ACI
�
SIZE OF LOT 4 ��a �.�-•' NOW ON LOT (� CITY73:� ll C•f TEL NO 2 j J 'AC��LS
USE OF
BUILDINGS DISTRICT NO GROUP MAP 2CEfSED BY
SK PG
t'
CONTRACTOR O w ~ ,09 ,
ADDRESS 7612- IA CAS O) Q, CONNECTION DATA
r"' �'f �ya fI l EPiX
CITY r,h!\ 1, �„i` TEL NO f�O O `l STATION D
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO GLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL M L TOP L
PUBLIC SEWER ! $7 00
SEPTIC TANK SEEPAGE PIT OR J C NO
PITS AND/OR DRAINFIELD 51000
CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL AFFIDAVIT NAIv[[ [A[[M[Ni RECORD INSTR NO DATE
WORK TO HOUSE SEWER $300 3 p�
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL $500 '
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING ce.
SEWER OR DISPOSAL SYSTEM B $300 STATE ENCROACHMENT CD
MANHOLE ® $7 00 PERMIT NO W
INDUSTRIAL 13-
WASTE
LWASTE APPROVAL C7
OWNERS PERMIT E 3 00 CHARGES
AUTHORIZATION I TOTAL FEE L CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS • DAY OF �[S 19�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT I
'` �1( 1 /�• CONNECT ADDITIONAL
ADDRESS-9-0---)2- ACI+i Q �l ' Y•l'� L.G c BUILDING OR WORK r
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,
DRAISEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY NFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR ,
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCRN IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THZAE�ESCRISED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATUREBACKFILL SEPTIC TANKS ❑OF PEQMTTTE /Y>y ��J�� SEEP PIT(S) ❑ CESSPOOLS ❑ \`
VALIDATI CK M O CASH
8 7 1.,A 6 �0 D 6.0 0 ego