HomeMy Public PortalAbout9014 ACASO DR_Sewer_4/17/1961_house sewer connection to public sewer 24650 INSERTS
.CEAPPLICATION FOR PERMIT
76AG42D 642D COUNTY OF LOS ANGELES �•
SEWER-SEAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Sup't of Building LOCALITY i U
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
DESCRIPTION LOT NO. OWNER LLEALv
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
?
USE0 1 01
BUIDISTRICT NO. GROUP MAP PROCESSED BY
ID
t BK PG
I
CONTRACTOR � j� •� � /yy/ ' I - 4-
ADDRESS CONNECTION DATA
✓'
CITY TEL.NO. •�' STATION DEPTH
ATE MANHOLE REFERENCE UP
REGISTRATION NO. � �..... ��,,,, COUNTY (yJ
NO. DESCRIPTION OVWORK FEE
HOUSE SEWER CONNECTING TO5-'11 „
® PUBLIC SEWER @ $3.00 c TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.
TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EX N.. CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO13 P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
a
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. U
ci. WORK TO HOUSE SEWER @ $1.00
SEWALTER OR DISPOSAL SYSTEM IR OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0. O
INDUSTRIAL U
WASTE APPROVAL W
CHARGES V)
OVVNERIS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLIJIG APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY ✓ 9 NEW HOUSE SEWER / t"
w OWNER ORet CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS ., SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS 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 AM PROPERLY REGISTERED ND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED B LOS ANGELES COUNTY AND TE OF ABANDON HOUSE SEWER ��•;
CALIFORNIA OR THAT 1 AM THE LEG L OWNER OF E ABOVE
DESCRIBED RESIDENTI PROPERTY. SEEPFPIT(S) ❑ CESBACKILIL SP00❑LS a7
SIGNATURE
OF PERMITTEE °
OF VALIDATIO ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
) C7 r' ii 17 ; 3 D 5.0 0 t,
[: