HomeMy Public PortalAbout5833 ALESSANDRO AVE_Sewer__ E808-10-71 APPLICATION FOR PMI C/
~COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
EPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGs ��fG�
ADDRESS 7S
lvd
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. _ �2
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS /y�� (/C) �. / //,/✓G
BK PG
CONTRACTOR BVI -� v� /.. /`J
ADDRESS I S /0
CONNECTION DATA
CITY TEL. NO. STATION /®� q` DEPTH
STATE LIC MANHOLE REFERENCE ,/// UPPER
LICENSE NO:. GLASS llf�• L ER
NO. .DESCRIPTION OF WORK FEE TYPE OF ON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. 3
vs
PUBLIC SEWER @ $7.00 fi P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR J r JOB NO.
PITS AND OR DRAINFIELD @ SIO.00 CO.IMP.NO. ///��� ,,�'f
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (�/ d
PRIVATE DISPOSAL SYSTEM @ S3.00 0 0 O
CONNECT ADDITIONAL BLDG.ORy� AFFIDAVIT WAIVER 'E.SEMENT RECORD. INSTR.NO. DATE u
WORK TO HOUSE SEWER @ $3.00 0
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL. @ S5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 83.00 STATE ENCROACHMENT W
MANHOLE $� DO PERMIT NO. d
INDUSTRIAL h
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 3 �00 V
AUTHORIZATION TOTAL FEE _ //� CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDCON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS D TE IN CTO R'S SIGNATURE
SIGNED THIS�D OF 9 19_
OWNER OR `�(,, NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
r BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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 REQUIR LOS ANGLES COUNTY AND STATE OF SEWAGE D ISPOSAL SYSTEM
CALIFORNIA OR THA T E LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB RIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEP IC TA ,A
SEEP.PIT'S
SSPOOLS ❑ /
VALID I N CK. M.O. CASH