HomeMy Public PortalAbout6028 AVON AVE_Sewer__ 6A64 2D 3 64
7APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING l
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL -J l
DESCRIPTION LOT NO _ OWNER
MAIL �✓ '�
BLOCK TRACT L� y�/f ADDRESS �^
NO OF BLDGS ��/
SIZE OF LOT NOW ON LOT CITY � TEL NO
USELDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG _
CONTRACTOR � � 1,/�/ G
ADDRESSCONNECTION DATA
CITY A414MIL NO 4I}�{3 STATION / ® DEPTH
STATE "Pomm.
REGISTRATION NO LI COUNTY MANHOLE REFERENCE
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
1 HOUSE SEWER CONNECTING TO Y CURB P L M L TOPIL
PUBLIC SEWER @ E5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR JOB NO G'
PITS AND/OR DRAINFIELD @ S1000 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAW=ECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 O
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 11.1
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
LDE
WNER'S PERMIT a 2 00
�— CONNECTION CHARGE FEE
HORIZATION TOTAL FEE
VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TOR TO COV NECT THE ABOVE DESCRIBED EXISTING DWELLING
HE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
NED THIS ,l[�p.�r/JDAy 0 - 19_
ER OR (fi�✓J '— NEW HOUSE SEWER
ERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS—
SE
RESS SEPTIC TANK SEEP PIT(S)
FREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
BING AND SEWERS CESSPOOL ❑ DRYWELL ❑
EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
NSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSA.SYSTEM
FORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
DE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
ATURE BACKFILL SEPTIC TANKS PERMITTEE i
SEEP PIT(S) ❑ CESSPOOLS ❑
ALMATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
- _ LAU0 9 1 5 4 JAN 2 6 1 0 A 7.0 0-