HomeMy Public PortalAbout9036 ACASO DR_Sewer_1/25/1972_sewer connection i a�e_ (�jj—
is 6272.0 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. re
(PRINT OR PE ONLY)
LEGAL 11
DESCRIPTION LOT NO. '9 OWNER
MAIL
BLOCK TRACT ,r-.
ADDRESS �y
O. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. QiF_
USE OF DISTRICTNO. GROUP CLASS MAP ��PR ESSED BY
BUILDINGS
BK pG 1
CONTRACTOR �"" ✓ Iq. �.U ' �3
ADDRESS /�}� C��ONNECTION DATA
CITY - L. NO. y STATION '7 // DEPTH
STATE LIC . ✓ /^� i UPPER
LICENSE NO: CLASS MANHOLE REFERENCE /Y
OWE
NO. DESCIAIFFTIOK OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOD !\ Y, CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 V
SEPTIC TANK,SEEPAGE PIT OR ! "7 P.C.NO.
/
CO.IMP.NO.
PITS AND/OR DRAINFIELD @ $10.00
/ JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 9'
PRIVATE DISPOSAL SYSTEM @ $3.00 a.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 u
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL,MANHOLE Q $5.00
ALTER.REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
V
PERMIT NO. Lu
a-
INDUSTRIAL W
OWNERS PERMIT $ o0
WASTE APPROVAL
CHARGES
,
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q __
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING pin
TO THE PUBLIC SEWER. APPROVALS D TE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT 1 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
'CESSPOOL ElDRYW ELL [IPLUMBING AND SEWERS:
I HEREBY CERTIFY TNA I AM'PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED LOS ANGLES COUNTY AND STATE-OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A THE LEGAL OWN OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV ESCRI BED AL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREBACKFILL SEPTIC TANKS ❑ {g� >�
OF PERMIT EAll
E SEEP.PIT(5) C3 CESSPOOLS
❑ fY
%DATION JACK R. LtW
.KUSUPERVISING MECHANICAL ENGINEER
_M.p.
LAW 4 0 c -9- Jill'2 5 1 0 D 1 0.0 0 M