HomeMy Public PortalAbout5330 ALESSANDRO AVE_Sewer__ ,0 62
78A842D APPLICATION FOR PERMI
78A 84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engmeer ADDRESS
WILLIAM A JENSEN Sup t of Buildmg
LOCALITY
NEAREST
FOR APPLI NT TO FILL IN CROSS ST
If 17
LEGAL
b ESCRIPTION LOT ` OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BL S
SIZE OF LOT NOW ON T CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESS D BY
P.
CONTRACTOR
ADDRESS !.-4 CONNECTION DATA
CITY TEL N a ` T TION 41 -_j DEPTH + r
REGISTRATION NO MANHOLE�� COUNTY � OWER
NO DESCRIP O O WORK E NECTION L LE H FROM
HOUSE SEWER CONNECTING TO TYP OFC NP L M L TO P L
PUBLIC SEWER @ $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $1000
CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO RO PERMIT NO
PRI VATE DISPOSAL SYSTEM @ S3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT XRD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 a.9
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCR CHMENT L/
PERMIT NO
INDUS 9 /)
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE Z
/ CONNECTION CHARGE FEE
I HAVE 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 INSPECTR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
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
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 AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM TH�J�GA L NER OF ND I TEND TO DISCONNECT PLUG AND
RESIDE IN THE AB E E C 51 ENT L POPE ABANDON HOUSE SEWER
SIGNATURE ACKFILL SEPTIC TANKS ElOF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L h,o 0 2 0 1:O S&13 1 0 a 7.00