HomeMy Public PortalAbout6041 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 Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST - J
LEGAL 1
DESCRIPTION LOT NO OWNER
MAIL (�
BLOCK TRACT ADDRESS '
NO OF BLDGS �:
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR
ADDRESS v,}� v CONNECTION DATA
STATION l .}-` DEPTH
CITY EL NO OOWFF ! V'
STATE MANHOLE REFERENCE
REGISTRATION NO B COUNTY // I CORM
NO DESCRIPTION OF WORK FEE TYPE OF CONN ECTIO P L LENGTH FROM /
HOUSE SEWER CONNECTING TO Y CURB M L TOP L
PUBLIC SEWER @ $5 00
PC NO
SEPTIC TANK SEEPAGE PIT OR }
PITS AND/OR DRAINFIELD @ E1000 JOB NO d
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLD G OR AFFIDAVIT wA1Yll I EASININT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER ® $300
OVERFLOW SEEPAGE PIT DRAINFIELD F_
EXTN CESSPOOL DRYWELL MANHOLE $500 U
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING ImAI 1 a
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENTC elm. H
PERMIT NO .'�c'�'(+j(� 5B {7
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT S 2 00 CHARGES
`�� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 6 SIGNATURE
SIGNED THIS DAY OF X19_ ✓
OWNER � NEW HOUSE
SEWER
OWNERS A �AGENT
ADDRESS � ✓ T� c CONNECT ADDITIONAL
BUILDING OR WORK
SEPTICTANK 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
LLING
COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
AND SEWERS CESSPOOL ❑ DRYWELL
Y CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REOWRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
THE ABOVE DESCRIBED RESIDE�L PROP RTY ABANDON HOUSE SEWER
E // BACKFILLSEPTIC TANKSITTEE ❑
SEEP PIT(S) ❑ CESSPOOLS
/---)VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
A0 9 1 5 7�8 JAN 2 6 1 0 A 700-
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