HomeMy Public PortalAbout9068 ACASO DR_Sewer_2/28/1962_97301 2465 INSERTS
76A642D60 APPLICATION FOR PER IT �,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS C; _
JOHN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Sup't of Building _LOCALITY
NEAREST
LEAL FOR APPLICANT TO FILL• 'INS^ CROSS ST.
DESCRIPTION LOT NO,.,/aat/ ZQ'� G y�S'f OWNER C,
BLOCK TRACT ;(L MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT O NOW ON LOT CITY 1 TEL. NO.
USE OF
BUILDINGS DISTRICT NO_f GROUP MAP PROCESSE r
CONTRACTOR 0 BK PG w) iW7 I c%-7
t/pJ�'
c
ADDRESS 6,J CO nNECTION ATA
CITY - TEL.NO. .` STATION C�, DEPTH l
n STATE MANHOLE REFERENCE '�//
REGISTRATION NO. C` COUNTY ►'V LO
NO. DESCRIPTION OF WORK FEE
wfa
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ _$j.00 ) TYPE Of EC
ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. URB.7 P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL, DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.NO.
_ PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOB NO. rk
p.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. I e� O
WORK TO HOUSE SEWER @ $1.00 U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 03
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. O
aal INDUSTRIAL U
_WASTE APPROVAL Pi
CHARGES y
OWNERS PERMIT g OD CONNECTION CHARGE FEE GI
AUTHORIZATION TOTAL FEE7 G REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCR ED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC NWER.
SIGNED THIS - DAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.PIT(S)
� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THI APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM TH LEG' C-Al WNER OF THE ABOVE
DESCRIBED RESIDENTI ROPER BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS;
OF PERMITTE
®PALIROBERT WOOD
�
CK. te.0.0. CASH SUPERVISING MECHANICAL ENGINEER
1 s 9 1 37-L ? 4,