HomeMy Public PortalAbout6040 AVON AVE_Sewer_1/26/1966_house sewer connection 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 BUILDING
JOHN A LAMBIE County Engu166r ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL Sr /
DESCRIPTION LOT NO V — OWNER
^s MAIL
BLOCK TRACT ADDRESS NO OF BLDGS PP7/
SIZE OF LOT NOW ON LOT CITY � `'TEL NO
USE OF
BUILDINGS .,' DISTRICT NO I GROUP MAP PR EBBED BY
BK PG
CONTRACTOR
ADDRESS CONNECTION D TA
y STATION !1 DEPTH f
CITY EL NO r V
El STATE MANHOLE REFERENCE UP
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FMROM
HOUSE SEWER CONNECTING TO Y CURB L ML TOIL
PUBLIC SEWER @ ss 00
SEPTIC TANK SEEPAGE PIT OR JOB NO a
PITS AND/OR DRAINFIELD @ S1000 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIOAL BLDG OR AFFIDAVIT WAIv [�Sf M[NT RECORD INSTR NO DATE O
WORK TO HOUSES EWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD ~
EXTN CESSPOOL DRYWELL MANHOLE @ SS o0 LTJ
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING a
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT s 2 00 CHARGES
AUTHORIZATION I TOTAL FEE &tq 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 INSPF"CTOR S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR / / NEW HOUSE SEWER '
OWNERS AGENT }� W� "Y//AAIIM�� CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(6)
I 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 ❑
I HEREBY 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 DESCRIBED RESIC�ENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS
OVALIDATION ROBERT A WOOD
cK M o CASH SUPERVISING MECHANICAL ENGINEER
LACO 9 1 5 6% JAM 2 6 1 0 A 7.0 0