HomeMy Public PortalAbout5741 ALESSANDRO AVE_Sewer__ 5 65
76A64 2D APPLICATION FOR P RMI
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING l� /
JOAN A 1 AMR11 county H nglneGr ADDRESS oIJC
COU MAN W JF NUNS Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN 7 CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
_ MAIL
BLOCK TRACT S �J / ADDRESS
NO OF BLDGS
SIZE OF LOT 1 NOW ON LOT 1.7— CITY TEL NO
USE OF / ^7_ '�/` DISTRICT NO GROUP MAP P ESSED BY
BUILDINGS �^'
BK PG
�
CONTRACTOR ,11Z oe
O ,y 1
ADDRESS JJJ CONNECTION DATA L
/ /�p STATION �L./ �/L� \^ DEPTH
CITY TEL NO
LICE NIS&Ei LICENSE
NO "--3CLASS MANHOLE REFERENCE J LOWER
NO GESCRIPTI ON OF WORK FEE TYPE OF CONN ION LENGTH FROM
HOUSE SEWER CONNECTING TO Y B P L M L TO P L r
1 PUBLIC SEWER C $ 5 00
SEPT I
TI ANK SEEPAGE P T R PC NO d
PITS AND
DRAINFIELD C $10 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM C $ 3 00 l LI
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W41VER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER C $ 3 00 O G
E AOR ABAND N HOUSE U
SEWER OR DISPOSAL SYSTFM C $ 3 00UVIIIILOW SEEPAGE PIT IIIAIIIIIILLI W
HWY ORST WIDENING n-
N
EXTN CESSPOOL MANI OLE C $ 5 00 STATE ENCROACHMENT Z
PERCOLATION TEST C $ 5 OG PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT IS z 00 CHARGES
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE FEE
� (�
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR 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)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
LO
COUNTY ORDINANCES AND STATE LAWS REGULATING
AND SEWERS CESSPOOL ❑ DRYWELL ❑
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IA OR T T I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
THE B VE DESCRIBED RESIDENTI PROPERYABANDON HOUSE SEWER
E BACKFILL SEPTIC TANKS ❑ITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
C�
CKALIDATION
M O CASH
LatJo 9 9 2 7 FEB 2 3 1 0 D 1000-