HomeMy Public PortalAbout5946 AVON AVE_Sewer_4/26/1965_house sewer connection to public sewer 6A64 f0-63 APPLICATION
IPPA ICA TION FOR PERMIT
76A642.D /`11f— Y� P"� 1 Itl tl-' Y`c PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer
ADDRESS
WILLIAM A. JENSEN, Sup't of Building 5946 e von ve o
LOCALITY
Se-B. Gabriel
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
[BLOCK
- MAIL e " er O
TRACT ADDRESS
NO. OF BLDGS. 5926 O O O p
SIZE OF LOT NOW ON LOT CITY rri r1lTEL. NO.
USE
OF
ReSl Bence -..,_ /
BUILDINGS DISTRICT NO. GROUP M P PROCESSED BY
CONTRACTOR �t +
1
ADDRESS O e CONNECTION DATA
�'1ry O STATION DEPTH
CITY Shy,T TEL. NO. _ �-�r
FAATE
PPER
REGISTRAT1012Q 525 ElCOUNTY MANHOLE REFERENCE \I=, Ups
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION C-LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 a
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. Y U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Q[
PRIVATE DISPOSAL SYSTEM @ $3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE H
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
a
EXTER,RESPOO R ABANDON ANHOLE @ $5.00 HWY.OR ST.WIDENING H
ALTER.REPAIR OR ABANDON HOUSE zSEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 OO
CONNECTION CHARGE FEE CHARGES
'-
AUTHORIZATION TOTAL FEE +� } .11
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING'..
f TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
_ SIGNED THIS DAY OF 19 �-
OWNER OR NEW HOUSE SEWER 6Or
OWNERS AGENT
eyyr CONNECT ADDITIONAL
LRES
S VY BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(5)
EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
LL COUNTY ORDINANCES AND STATE LAWS REGULATING
NG AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
HERE CERTIFV�,TH 1 AM PROPERLY REGISTERED AND�GR ALTER,REPAIR,SEWER OR -
ED AS REO R B� LOS ANGLES COUNTY ANDS/FATE OF SEWAGE DI S POSAL SYSTEM
RNIA OR T I AM THE LEGAL OW OF, AND INTEND TO
DISCONNECT PLUG AND
IN, THE OVE,�DESCRIBED RESI TIAL P PE Y. ABANDON HOUSE SEWER
URE /,/,/ BACKFILL SEPTIC TANKS.❑RMITT ❑
SEEP,PITIS) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
ii iJG 9 ft;'rt _ 0 A
7.00)-
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