HomeMy Public PortalAbout5727 ALESSANDRO AVE_Sewer__ 62
76AS42D I APPLICATION FOR PERM
6A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NOIF, tJ V , 50 b OWNER
MAIL
BLOCK TRACT 6 ADDRESS
NO OF BLDGS I�
SIZE OF LOT O NOW ON LOT CITY TEL NO U
USE OF
BUILDINGS DISTRICT GROUP MAP PRINCES BY
)BK PG
CONTRACTOR,�
ADDRESS V V Jr� CO ECTION DATA
CITY TEL N STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
l
NO DESCRIPTION OF WORK FEE TYPE OF CO C ION LENGTH FR
HOUSE SEWER CONNECTING TO .mow Y UR P L M L TO P L S
PUBLIC SEWER @ $5 00 O
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO O O
PRIVATE DISPOSAL SYSTEM @ $3 00 TRUNK PERMIT NO ROAD PERMIT
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
E%TN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN MED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESC IBED EXISTING DWELLING
TO THE PUBLICSEW APPROVALS DATE INSPECTOR 5 SIGNATURE
SIGNED THIS E DAY OF 19 „ ..may_�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ - I CONNECT ADDITIONAL 0
Gam// BUILDING OR WORK
ADDRESS CCC
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
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/ AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV ..p ESCR BED RESIDENTIAL PR P RTY ABANDON HOUSE SEWER �..�
SIGNATURE OF PERMffTE r '__;jL ' BACKFILL SEPTIC TANKS ❑ A� /,�(fl � "�
SEEP PITS) ❑ CESSPOOLS
VALIDATION RINGER+T A WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER
CAS)ti
2 5 4--o' vLIIN 14 1 I0 D 7.00-
h