HomeMy Public PortalAbout6248 AVON AVE_Sewer__ 6A6420 65
7APPLICATION FOR PERMIT
76A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING a1 /�) a�V^�
JOHN A LAMBIF County FngmPer ADDRESS d IV #4
C 01 FNIAN W JFNKINS Sup t of Building p I
LOCAL TV Y ��b^I� •
NEAREST /O ' /� /�s►�f
FOR APPLICANT TO L IN CROSS Sr ('� IV v��/�►<
DE SCRIGP AL ION LOT NOAl OWNER IMAIL
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BLOCK TRACT 5y 40/ ADDRESS�� 3� Q�� —.4cL
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY PAYS. TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP/' PROCESSED BY
BK PG
CONTRACTORe, V/s LRl ��l� / J .0 f �l 7 /-0 O ?,--
ADDRESS �j790 to / 39 tat 51"t C`ONNNECTION DATA � v
CITY /T� TEL NO /� STATION /Z �� DEPTH
NIOCE NS 03 /- J LLA SSSS `_ MANHOLE REFERENCE od:F!/� L
NO GESCRIPTION OF WORK FEE TYPE OF CONNECTION v LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER 0 $ 5 00
SE -PTITANKE AG T R PC NO a
PITS AND/OR GRAINFIELD C $10 00 CO IMP NO JOB NO
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM 9 $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER C' $ 3 00 O _
`�
SEWER C $ 3 0010 4 ��
HWY OR ST WIDENING
EXTN CESSPOOL MANI OLE Co $ 5 00 STATE ENCROACHMENT N
PERCOLATION TEST C $ 5 00 PERMIT NO
INDUSTRIAL I
WASTE APPROVAL
OWNERS PERMIT 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
E
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 OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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 A LES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM T,�-IE L A 0W1�eR OF AND INTEND TO DISCONNECT PLUG AND V
RESIDE IN THE VE RIBE ESI PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM ITTE SEEP PITS) ❑ CESSPOOLS ❑
OVALIDATION
CK M O CASH
LhC0 9 2 6 11 JUN 2 3 1 Q D 5 0 0