HomeMy Public PortalAbout5326 ALESSANDRO AVE_Sewer__ 6AG420 82
7APPLICATION FOR PERMIT
8A84
COUNTY OF LOS ANGELES ,OQ
SEWER—SEWAGE DISPOM
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Eng>neer ADDRESS
WILLIAM A JENSEN Sup t of Bu>ldmg
LOCALITY
NEAREST
FOR APPLICANT TO FML IN CROSS ST
LEGAL '
DESCRIPTION LOT NO A OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PG PRO SED BY
BUILDINGS
CONTRACTO -. �K
ADDRESS CONNECTION DATA
CITY EL NO l / T TION DEPTH
w .. 1ENC
/
REGISTRATION NO96 COUNTY M A N H FBR + f� OWER
NO DESCRIPTION F WORK _FELF TYPE CO E aNGTH FROM^
HOUSE SEWER CONNECTING TO O L M L TO P L 3 V
PUBLIC SEWER ;5 00
SEPTIC TANK SEEPAGE PIT OR CO IMP NO 1B9-NCO✓Gi /�
PITS AND/OR DRAINFIELD C S1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO D A-r E
WORK TO HOUSE SEWER $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 O
ALTER REPAIR OR ABANDON HOUSE 5
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMEN
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT $ 2 00 _ CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE�
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS D TE INSPECTOR S SIGNATUR
SIGNED THIS DAY OF 19_ R
OWNER OR NEW HOUSE SEWER / Ip
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS 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 VE DESC IBED REN�TIAL P ERTY ABANDON HOUSE SEWER
SIGNATUREBACKFILL SEPTIC TANKSOF PERMITTEESEEP PITfS) r-1CESSPOOLS ❑
VALIDA ON ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK
9M O CASH
Llo 0 1 9 8GO SEP 13 1 0 0 700- 1