HomeMy Public PortalAbout5336 ALESSANDRO AVE_Sewer__ 3 64
76A64 2D APPLICATION FOR PERMIT
6A64 ,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer DDRESS
WILLIAM A JENSEN Sup t of Build>ng
LOCAL TY Q1
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL `
BLOCK TRACT ADDRESS I U
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY / TEL NO
USE OF DISTRICT NO I dROU4MAP P OCESSED BY
BUILDINGS
PG
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CONTRACTOR l'`1 ll L/
ADDRESSCONNECTION DATA
STATION DEPTH
CITY 'y1� C TEL NO
`^� r STATEMANHOLE REFERENCE UPPER
REGISTRATION NO `v COUNTY
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER f5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO d
PITS AND/OR DRAINFIELD @ S1000 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL OWSWOM VER I EASEMENT RECORD INSTR NO DATE 0
O
WORK TO HOUSE SEWER $30
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 W
CL
ALTER REPAIR OR ABANDON HOUSE HWY OR S7 WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
06
AUTHORIZATION TOTAL FEE ti N
PERMIT NO ] Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00
CONNECTION CHARGE FEE CHARGES
1 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 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK BEEP PIT(6)
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 Cl
1 HEREBY CERTIFY THAT M PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I M LEG L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV D SC RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
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