HomeMy Public PortalAbout5420 ACACIA ST_Sewer_4/26/1962_sewer connection CESOB 3-61 wV
76AG42D APPLICAT ON FOR P - ,RIV
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
..DEPARTMENT OF COUNTY ENGINEER """'""`"$ -
BUILDING AND SAFETY DIVISION BUILDING 7p �� c �`
JOHN A, LAMBIE, County Engineer ADDRESS . G
WILLIAM A JENSEN, Sup t of Building LO�A"LI a
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
9
BLOCK TRACT MAIL
NO OF ADDRESS
SIZE OF LOT NOW ON LOTS CITY TEL NO
USE OF
BUILDING DISTRICT NO GROUP YAP PROCESSED BY
BE Pe
CONTRACTOR l WaAA
AD'RESS `Z E L� CONNECTION DATA
w CITY TEL NO STATION irlDEPTH'
STATE
REGISTRATION NO a COUNTY MANHOLE REFERENCE ��` UPPER I
'ONO v'- —DESCRIFTION OF WORK FEE —
.w '0 h 116USVSEWER CONNECTING TO J
._� iPUBLIC�SEWER @ S 00CONN LENGTH FROM
'-'SEPTIC TANK SEEPAGE PIT OR Y np C ,rdl. M L TO P L
1! PITS'AND/OR DRAIN FIELD @ 00
Ilk EXTNFLCESSPOOLGDRYWELLAINFIELD S 00 C
HOUSE SEWER CONNECTING TO P C N0. 0
s . PRIVATE DISPOSAL SYSTEM @ 11 00 CO IMP NO JOB NO V
CONNECT ADDITIONAL BLDG OR I
TRUNK PERMIT NO ROAD PERMIT NO
IzWORK TO HOUSE SEWER S 00 d'
',-ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT Q
SEWER OR DISPOSAL SYSTE @ $
00 PERMIT NO
INDUSTRIAL
L WASTE APPROVAL N
CHARGES Z
DwNimss PERM 51 2 00 CONNECTION CHARGE FEE
:AUrTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1'HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, `
< ..,tet ,.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING, APPROVALS I DATE ' INSPECTOR S SIeNATURE
TO THE PUBLIC SEWER <
SIGNED THIS DAYO 18_' NEW HOUSE SEWER /
OWNER OR C J BCO
UNNECT ADDITIONAL
OWNERS AGENT
ADDRESS SEPTIC TANK SEEP PIT(S) !' I
AND/OR DRAINFIELD
IA HEREBY ACKNOWLEDGE THAT L HAVE READ THIS APPLICATION_ I_
AND`STATE'THAT THE ABOVE SS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL 13
WITH ALL C LINTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMB N SEWERS SEWAGE'DISPOSAL SYSTEM
1. H BY CE TIFY THAT 1 AM PROPERL REGISTERED AND/OR DISCONNECT PLUG AND
LICE D AS OUIRED BY LOS ANGE S C NTY AND STATE OF ABANDON HOUSE SEWER
CALI NIA 10 THAT I AM T LE L 0 NER OF THE ABOVE,'
DE_SC ED R ENTIAL PROPE ,I BACKFILL SEPTIC-TANKS
SIGMA_, SEEP PITS SP00 Ls
OF-,PERMITTE ` U 4
ALIDATION ROBERT A WOOD
Cc M o cum SUPERVISING MECHANICAL ENGINEER
��� 1 6 9 5 OR 2 6 0 0 7.0 0 r