HomeMy Public PortalAbout9059 ACASO DR_Sewer_3/12/1962 We 1�1_
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76A642D APPLICATION FOR PERMIT
BA64
COUNTY OF LOS ANGELES . , SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F'q
a'JOHN A, LAMBIE, County Enaneer sr -
WILLL4M A JENSEN, Supt of Buildmq FOR APPLICANT TO FILL IN
LEGAL �� OWNER +, '
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS �- P
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY a. TEL NO
USE
ELDINGS OF DISTRICT NO' +GROUP MAP 'PROCESSED BYBUIt* 8
BK PO
CONTRACTOR �
ADDRESS CONNECTION DATA
CITY TEL NO + D STATION j DEPTH
Jf CSTATE OUNTY MANHOLE REFERENCE ` L,
REGISTRATION NO LOWER
No I DESCRIPTION OF RX FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ S 00 TYPE OF CTION LENGTH FROM
PETS AND/OR DRAINFI LDT OR S 00 Y CUR P L Y L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD p}-
EXTN CESSPOOL DRYWELL @ S 00 P C NO O
HOUSE SEWER CONNECTING TO CO IMP NO J JOB NO atU
PRIVATE DISPOSAL SYSTEM @ S 00
WORKTO DDITIONAL BLDG OR S1 00 TRUNK PERMIT NO ROAD PERMIT NO tsr s
HOUSE O
A(,TER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT ~
SEWER OR DISPOSAL SYSTE @ S 00 PERMIT NO V
W
INDUSTRIAL CL
N
WASTE APPROVAL
CHARGES ?
OWNWS PERM E 2 .00 CONNECTION CHARGE FEE
,AUTHORIZATION r TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT,.THIS DATE A CONTRACT WITH THE HEREIN N ED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE, r +,
TO THE PUBLIC SEWER.
SIGNED THISD Y P 9 HOUSE SEWER ;K
OWNER
OWNER OR , CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRES —SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD +
1 HEREBY+ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION'
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYLDISCONNECT
❑ DRYWELL WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGPAIR SEWER OR
PLUMBING AND SEWERS ISPOSAL SYSTE1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/ORCT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF• HOUSE SEWER
CALIFORNIA OR THAT 1 AN THE LE6 OWNER OF THE AB YE SEPTIC TANKS DESCRIBED RESIDENTIAL PROPE TY. (S ❑ CESSPOOLS
SIGNATURE` .'
OF PERMITTE —k .�
ON
VALIDATIO ROBERT A. WOOD
CIL Y o Wtl SUPERVISING MECHANICAL ENGINEER
L"P9478 % IRM121 0 D 5.00 5
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