HomeMy Public PortalAbout5315 ALESSANDRO AVE_Sewer__ 3-64
76A643-64
APPLICA"T"ION FOR PERMIT'
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIN
JOHN A. LAMBIE, County Engineer ADDRES
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST ,
FOR APPLICANT TO FILL IN J CROSS ST.
AL
DESCRIPTION LOT NO. A V' ` QZ Q / OWNER
MAIL
BLOCK TRACT ` Q. / ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY !TEL. O.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRACTOR -•�
ADDRESS . CONNECTI N DATA
STATION r DEPTH I
CITY L. NO. (/ �7
REGISTRATION NO. pC p 3 ElCc MANHOLE REFERENCE �{ UPPER
OUNTY
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION / LENGTH FROM
HOUSE SEWER CONNECTING TO Y. l CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TAK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP.NO. JOB NO.
N /± f7,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NOy 7C V
PRIVATE DISPOSAL SYSTEM @ S3.00 L :J
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ 53.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 LU
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 83.00 STATE ENCROACHMENT H
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT � z 00
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
'I HAVE 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
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTICTANK,SEE-',PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIED
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I [HE LE OWNER OF, ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO E RI ESI DENTI OPERTY. ABANDON HOUSE SEWER
SIGNATURE ACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP.PIT(S) ❑ CESSPOOLS ❑
/ /VIALIDATION ROBERT WOOD
l SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
uI1L,Q7 7 5 S'S' DEre 2 1 0 D 7.0 Or!!