HomeMy Public PortalAbout9059 ACASO DR_Sewer_8/31/1972 t
76Aa4zo' APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUDILDING b J G b
JOHN A. LAMBIE. COUNTY ENGINEER ADRESS J
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY .Pi
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
(PRINT OR TYPE ONLY)
LEGAL p
[DESCRIPTION LOT NO. OWNER aMAILLOCK TRACT rV ADDRESSNO. OF BLDG5.IZE OF LOT NOW ON LOT CITYTEL. NO.
SE OFUILDINGS L� N 4003� DISTRICT NO. GROUP CLASS BK MAP PS 'ED BY
If f
CONTRACTOR � �� �� ��( �•✓1 /N sig✓.
ADDRESS CONNECTION DATA �W
STATION DEPTH
CITY � TEL. NO.
STATE LIC MANHOLE REFE ENCE UPPER
LICENSE NO. CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGP<FROM
HOUSE SEWER CONNECTING TO Y. CUR P.L. M. O P.L.
PUBLIC SEWER @ $5.00 P.0 O.
SEPTIC (ANK.SEEPAGE PIT OR
CO.IMP. NO. J NO.
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. >-
PRIVATE DISPOSAL SYSTEM @ $3.00 d
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Wl11 YEN E�SEM[ CORD.INSTR. NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDE NG
SEWER OR DISPOSAL SYSTEM $3.00 ~
STATE ENCROA MENT U
PERMIT NO. LI.1
a
INDUSTRIA En
WASTE APPR VAL Z
CHARGES
OWNERS PERMIT $ 00
AUTHORIZATION TOTAL FEE .) CONNECTION CHARGE FEE
1HAVE 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 G
OR '^y,1J 13 NEW HOUSE SEWER
OWNERS AGENT A 1»ED L12tt� s( y
CONNECT ADDITIONAL
ADDRESS
90 lC r I�.. S6 /1n, BUILDING OR WORK
7 ) r�C�. (�
SEPTIC TANK.SEEP,PIT(S) a
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD 4'•� ''
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ � -.1 -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR -
LICENSEDAS 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 ABOV DES IB D RESIDENTIAL PROPERTY.
ABANDON HOUSE SEWER -
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE - `` ❑
SEEP.PIT T(S) ❑ CESSPOOLS
VALIDATION JACK R. ALLEN
OSUPERVISING MECHANICAL ENGINEER
I CK. M.O. CASH
R
= 1D 31 1 D 6.00�'