HomeMy Public PortalAbout5937 AVON AVE_Sewer_4/26/1965_House sewer to public sewer 6A64 10-63 APPLICATION FOR PERMIT
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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, Sup't of Building von . v e,
t LOCALITY
NEAREST
San -Gabrie!
FOR APPLICANT TO FILL IN `ROSS BT.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL Weber e
BLOCK TRACT ADDRESS
NO. OF BLDGS. 5926 X- ♦ p pBlvd.
SIZE OF LOT NOW ON LOT CITY TEL. �NO.
USE OF Residence i. DISTRICT NO. GROUP MA _ PROCESSED BY
BUILDINGS
' CONTRACTORHenry B .
ADDRESS a CONNECT3245 ION DATA
N. 17ar Ave0
CITY SSG.
TEL. N � STATION F - DEPTH
-P; REGIST RATIOKJ ALO'J 525 ❑ COUNTY 51,
STATE MANHOLE REFERENCE V I ` UPPER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM GJ'
HOUSE SEWER CONNECTING TO Y. CURB .L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD {JJ
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 O.
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
q WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE
' AUTHORIZATION TOTAL FEE
'I 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'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER ORNe♦AT NEW HOUSE SEWER
OWNERS AGENT VV 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 IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERp CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIF`p/ T I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS RE LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I ASM THE LEGAL OW� F. AND IIT,01D TO DISCONNECT PLUG AND
RESIDE IN, TH BOVE�DESCRIBED RESIDE. L PROP�RT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM( E ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH
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