HomeMy Public PortalAbout5319 ALESSANDRO AVE_Sewer__ ® 246p550 INSERTS
76A642-80 APPLICATION FOR PERMIT
�sAeazo COUNTY OF LOS ANGELES 6 al FORSEWER-SEWAGE
DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 2
ADDRESS J
JOHN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss Sr.
LEGAL �r r
DESCRIPTION LOT N0. OWNER�y
BLS TRACTMAIL
J ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF N40 (G:Ra0UP DISTRICT MAP PROCESSED BY
BUILDINGSBK PGCONTRACTOR
ADDRESS l� CONNECTION 9DATA
CITY TEL.NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATI N N0. COUNTY LOWER
NO. DESCRIPTION OFW ORK FEE I f
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 - CO. IMP. NO. JOB N0. >•
CONNECT ADDITIONAL BLDG.ORP.
WORK TO HOUSE SEWER @ $1.00 rRUNK PERMIT N0. ROAD PERMIT N0. O
U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACH T
SEWER OR DISPOSAL SYSTEM @ $1.00PERMIT N0. p
INDUSTRIA V
WASTE AP OVAL W
0.
CHAR S U1
OWNER'S PERNIIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
THE HEREIN NAMED CON.
TRACTOR TO CIONNECT THE ABOVE ES DATE A CONTRACTH IBED EXISTING DWELLING .. APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. a
SIGNED THIS__� -D OF 19 NEW HOUSE SEWER
OWNER OR
,_ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS - SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING --.
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIR D LOS ANGE ES OUNTY AND STATE OF `, ABANDON DISCONNECT
HOUSE D
CALIFORNIA OR THAT M THELE A OWNER OF THE ABOVE
ER
DESCRIBED RESIDENT L P OPER '_ BACKFILL SEPTIC TANKS ❑
Nl
SEEP. PIT(S) ❑ CESSPOOLS ❑
SIGNATURE
OF PERMITTE
®" ALIDATION ROBERT A. WOOD
cIc M.o. CASH SUPERVISING MECHANICAL. ENGINEER
.� 6 to 4 8 ,;AU :L i `4? D
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