HomeMy Public PortalAbout6128 AVON AVE_Sewer__ l
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[CEb09 APPLICATION FOR PERMIT
4
6A 542 D D
' 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
LEGAL /� OWNER
DESCRIPTION LOT NO � ~(!
BLOCK TRACT Q MAIL
ADDRESS
NO OF BLDGS
1 SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROU MAP R� OC_ESSED
"ONTRAC
-ADDRESS c CO CTION DA A
Ell `J EL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO `~ OUNTY LOWER
NO DESCRIPT N OF WORK FEE
HOUSE SEWE CONNECTING TO
PUBLIC SEWER @ $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ 33 00 Y CURB P L M L TO L
OVERFLOW SEEPAGE PIT DRAINFIELD / n}
EXTN CESSPOOL DRYWELL @ 52 00
HOUSE SEWER CONNECTING TO P C NO 0
ti PRIVATE DISPOS L SYSTEM @ St 00 CO IMP NO / JOB NO U
CONNECT ADDITIONAL'
WORK TO HOUSE SEWER @ $ 00 TRUNK PERMIT NO ROAD PERMIT NO a'
ALTER
OR DISPO AL SYSTEM HOUSE @ $100 STATE ENCROACHMENT O
PERMIT NO U
LLJ
INDUSTRIAL IL
WASTE APPROVAL Cn
CHARGES ?
OWNER S PERMIT 51 2 1 00 CONNECTION CHARGE FEE
AUTHORIZATION rTOTAL FEE REIMBURSEMENT FEE
NAMED CN
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRAWITH THE I+NG DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OP 19- NEW HOUSE SEWER 1
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK --
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEN
I HEREBY CERTIFY THAT I AM PROPERL R STERED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES C UNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE EGAL 0 ER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDEN PER SEEP PITS ❑ CESSPOOLS
SIGNATURE a 7
OF PERMITTE
VAMATION.---\ ROBERT A WOOD
CIC C o LCA9R SUPERVISING MECHANICAL ENGINEER
JUL 3 1 0 A 5 00-
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