HomeMy Public PortalAbout4935 ALESSANDRO AVE_Sewer__ 0-63
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEARST
JOHN A. LAMBIE, County EngineerWILLIAM A. JENSEN, Supt of BuildingFOR APPLICANT TO FILL IN
DESCRIPTION AL - - LOT NO. OWNER
�J MAIL
BLOCK TRACT 146 y ( � ADDRESS
NO. OFBLDGS. /
SIZE OF LOT NOW ON LOT L/ CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG 7
CONTRACTOR y - f �����•. _ "!• a `" V -3 /
CONNECTION DATA
ADDRESS IF�' �)_•,
• STATION DEPTH
CITY \�w•%`1�-�I TEL. NO.
` l _ STATE UPPER
REGIST TION NO. / (- 5 �' �� / COUNTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. C
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. N JOB NO.
U
HOUSE SEWER CONNECTING TO TRUN P I N 7, AD PERMIT NO. d•
PRIVATE DISPOSAL SYSTEM @ $3.00 1 / 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT I RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 U
LLI
OVERFLOW SEEPAGE PIT,DRAINFIELD Fd
CIL
EXTN.,CESS POOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR_D_ISPOSAL SYSTEM @ $3.00 f STATE ENCROACHMENT
PERMIT NO.
-- INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ i 00
AUTHORIZATION I TOTAL FEE C90'�'h CONNECTION CHARGE FEE
-IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(5)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE..DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE/DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMIT T EE_ ! �� BACKFILL SEPTIC TANKS ❑
SEEP.PITS) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
"02 8 6 21—�o AUG2 0 1 0 D 5.00- 14