HomeMy Public PortalAbout5426 ACACIA ST_Sewer_9/14/1965_house sewer connection to public sewer 76A642DE4 APPLICATI N FOR PERMIT -
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
rOHN A LAMBIE. County Engineer ADDRESS
WILLIAM A JENSEN, Supt of Bulldurg
LOCALITY
NEARES
FOR APPLICANT TO FILL IN CROSS sT O
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PG PROCESSED BY
CONTRA
ADDRESS CONNECTION DATA
ST ION DEPTH
CITY �f ( .� TEL O
STATE MANHOLE REFERENCE
RE STRATTON NO /r/�i- COUNTY y`- OWER
N DESCRIPTION OF WORK FEE TYPEOF ONNE LENGTH FROM
HOUSE SEWER CONNECTING TO Lf a Y L ML TO P L ��
PUBLIC SEWER iS 00 vP C NO
EPTIC TANK SEEPAGE PIT OR
SCO IMP NO JOB NO
PITS AND/OR ORA
ELD $,D 00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NV
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVES EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER $300 0
OVERFLOW SEEPAGE PIT DRAINFIELD 7
EKTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HW T �—
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
�
OWNERS PERMIT $ i 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE 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 5 SIGNATURE
SIGNED THIS OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED OUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN OR NAT 1 AM THE L L OW OF AND INTEND TO DISCONNECT PLUG AND
RESIDE TH ABOVE DESCRIB ESI N AL PROPERTY ABANDON HOUSE SEWER I
SIGNAT E BACKFILL SEPTIC TANKS ❑
OF P SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
L&05 5 5 5 SEP 14 1 0 D 7.00-
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