HomeMy Public PortalAbout5826 ALESSANDRO AVE_Sewer__ 768085
76A6420 65 APPLICATION FOR PE MIT {�
u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LANIBIL County Engineer ADDRESS
COLEMAN IX JENKI\S Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL t
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USEOF f S DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS /��12'f
CONTRACTOR ��� �• �fVK�.- f3
ADDRESS 2 �r— CONhNECTION DATA
CITYsTEL NO �� f ¢ STATION Lo // DEPTH /
LICENSE TEL
NO (I� CLASS 2 MANHOLE REFERENCE t LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEI4GT.F M
PHOUSUBLICS EWER CONNECTING TO C $ 5 00 ad Y RB P L M L TOP
PC NO >-
SEPTIC ANK SEE AGE PIT R d
PITS AND/OR GRAINFIELD C $1 0 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO L)
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlven eAS EN[xr RECORD INSTR NO DATE C
WORK TO HOUSE SEWER C $ 3 00 O
REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTFM C $ 3 00
HWY OR ST WIDENING a
EXTN CESSPOOL MANI OLE C $ 5 00 h
STATE ENCROACHMENT
PERCOLATION TEST C $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE 7 CONNECTION CHARGE FEE CHARGES
10
1 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 INSPECTOR E
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
76
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 15 CORRECT AND AGREE TO COMPLY
WIT HALL 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 IAM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL P OPERTY ABANDON HOUSE SEWER
SIOF APERM I77EE BACKFILL SEPTIC TANKS El TURE
/��� \
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION��,
CK M O �{ SH
Lt vc' 4 3,� oLJ'T 1 g _ D 7 0