HomeMy Public PortalAbout6013 AVON AVE_Sewer_10/13/1965_connect house sewer to public sewer 3 64
76A64 2D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGJ.Y JOHN A LAMBIE County Engineer ADDRESSWILLIAM A JENSEN Sup t of BuildingLOCALITYNEARESTFOR APPLICANT TO FILL INCRD55 S7
LEGAL DESCRIPTION LO7 NO 6 OWNERMAILBLOCK f�TRACTADDRE 5SIZE OF LOT ' v� r(J NO OON LOTS CITYNOUSE OF DISTRICT NO GROUP MAP CE
BUILDINGS
BK PG
CONTRACTO
ADDRESS CONNECTION DATA Za)
CIT EL NO STATION 0 DEPTH
TATE S UPPE
REGIST RATIO NO ® COUNTY MANHOLE REFERENCE i LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR13M
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC BEW ER $5 00 P C NO }
SEPTIC TANK SEEPAGE PIT OR CO IMP NO O JOB NO D_
PITS AND/OR DRAINFIELD @ fl0 00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM @ f3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVII IAIIMINT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 O
OVERFLOW SEEPAGE PIT DRAINFIELD I
EXTN CESSPOOL DRYWELL MANHOLE @ 3500 U
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING lJ.l
a
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO _
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES fzT ED EXIST NG DWELLING APPROVALS
TO THE PUBLIC SEW R DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19!
OWNER OR NEW HOUSE SEWER V �
OWNERS AGE
CONNECT ADDITIONAL d r
BUI DIG OR WORK
ADDRESS
SEPTICNTANK SEEP PITS)
I HEREBY AC KNOV✓LEOGE THAT I 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 ❑
1HEREBY 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 I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE D CRIBED RE51 ENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LACO6355u\D' OCT 131C A 7.00-