HomeMy Public PortalAbout6037 AVON AVE_Sewer_1/26/1966_house sewer connection to public sewer 76A64 3-64 APPLICATION FO® PERMIT �I
76A642D fS PERMIT I�LJIII
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
IOHN A. LAMBIE, County Engineer
ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST t
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER '✓�' r
a MAIL
BLOCK TRACT + /c9, 1 ADDRESS
NO. OF EILDGS.
SIZE OF LOT NOW ON LOT CITY ✓TEL. NO.
USE OF ,�� l � 1
BUILDINGS ,..�� �+f/..4 i<� DISTRICT NO. GROUP MAP PR CESSEW15Y
BK PG
CONTRACTOR ? 4,,.' ' r
ADDRESS CONNECTION DATA^� � �' If „J�� ,{��=r
STATION / DEPTH
UPPER
STATE
REGISTRATION NO, ElCOUNTY MANHOLE REFERENCE C -69MAMIN
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO Y. CURB P.L M.L.TO P.L.
37
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT-OR JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00 _
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 LI
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION I TOTAL FEE .� CONNECTION CHARGE 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 O((F - 19_
OWNER OR i ,��. ..t. � � NEW HOUSE SEWER
OWNERS AGENT �`L
�� CONNECT ADDITION AL
ADDRESS D' O '7� BUILDING OR WORK
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS 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 DESCRIBED RESIDE TIAL PROPER Y. ' ABANDON HOUSE SEWER
/ F
SIGNATURE , (�/I�,/��,. 7`�
OF PERMITTEE_ a'" +r _ BACKFILL SEPTIC TANKS ❑
'7 SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
L,AL;O 9 1 5 8- JAN 26 1 0 A 7.0 0-