HomeMy Public PortalAbout5324 ALESSANDRO AVE_Sewer__ KEBOB 10 ez
78A8420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER T
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRD53 ST
LEGAL
DESCRIPTION LOT NO /f �� OWNER
MAIL
BLOCK TRACTzy
ADDRESS
NO OF BOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP
BUILDINGS PG PROCE E BY
BK
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO J STATION DEPTH
�� MANHOLE RE ERENCE UPPER
REGISTRATION NO III "'iii CUUN7Y LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 P C NO V
SEPTIC TANK SEEPAGE PIT OR CO IMP NO / JOB NO
PITS AND/OR DRAINFIELD $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVE N EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 ;/ p
OVERFLOW SEEPAGE PIT DRAINFIELD hy
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 b
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z o0
AUTHORIZATION TOTAL FEE ��— 1J� CONNECTION CHARGE FEE
IHAVE 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 19_
OWNER OR NEW HOUSE SEWER S
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK 1
ADDRESS SEPTIC TANK SEEP PIT(S)
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 CESSPOOL Ell DRYW ELL 111
PLUMBING AND SEWERS
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 B E DESCRIBED R NTI PROPER ABANDON HOUSE SEWER
SIGNATURE / CKFILL SEPTIC TANKS ❑
Z,OF PERMITTEE EP PIT(S) [:1 CESSPOOLS
s ALIDATION ROBERT A WOOD
h �1/ SUPERVISING MECHANICAL ENGINEER
G CK M O CASH
jqa O 1 9 7.0 SO 13 1 0 0 5.0 0 Q