HomeMy Public PortalAbout6200 AVON AVE_Sewer__ 76A 642D -CE808 -10 71
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 1V 6200 TT• Avon Ave.
LOCALITY San Gabriel
FK
OR APPLICANT TO FILL IN NEAREST Garibaldi
CROSS ST
Richard Bowen
ION LOT NO � OWNER
TRACT O MAIL 1620 Melanie Ln.
ADDRESS
NO OF BLOGS
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LOT NOW ON LOT CITY TEL NO
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S LL1l �s DISTRICT NO GROUP MAP CESSED BY
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TORS uare Deal Sewer Service ,-.-�,J0 rl ""� O-L-- lG�c
2933 Maxson Rdf.� CONNECTION DATA
l MonSTATE ]Qte TEL NO 444-LIC1210��20 STATION �� DEPTH d
LICENSE NO 12 V 870 C ASS V-42 MANHOLE REFERENCE 2_6 /^Z 2-'jVLOWER
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO ��++)) Y CURB p L� M L TO P L
PUBLIC SEWER @ $7 00 V P C NO
SEPTIC LANK SEEPAGE PIT OR CO IMP NO 33o JOB NO
PITS AND/OR DRAINFIELD @ $10 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ S300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE u
IF WORK TO HOUSE SEWER $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT W
PERMIT NO
MANHOLE $7 00 4.
N
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE zo 00 CONNECTION CHARGE FEE
IHAVE 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 OF 19_ /J
OWNER OR NEW HOUSE SEWER -43 /
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 RESIDEN AL P OPERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMITTEE BACKFILL SEPTIC T 5
SEEP PIT(S) CES OOLS ❑
VALIDATION (cK M O CASH
031L'-r'htAH SIV U l UU � ��
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