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HomeMy Public PortalAbout9015 ACASO DR_Sewer_12/27/1963_sewer connection 76A642 D.82 APPLICATION ®®1 CATION FO® PERMIT 78A 842D /`i f_1-1.. /°"� 1 �V 1- fT PERMIT IVB COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS ®/.2� WILLIAM A. JENSEN, Sup't of Building f LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS 5T. LEGAL DESCRIPTION LOT NO. OWN CR MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. r SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY /( BK �///PG CONTRACTO , P (J ADDRESS ,�' CONNECTION DATA '$ L STATION O` DEPTH Y TEL. NO. c7/� �T'TATE MANHOLE REFERENCE T UPPER REGISTRATION NO. / �/ ❑ COUNTY Z I NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO /�v��r Y. CURB P.L. M-L.TO P.L. O PUBLIC SEWER @ $5.00 S/1G/ SEPTIC TANK,SEEPAGE PIT OR P.C.NO. (g PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 0 CONNECT ADDITIONAL BLDG.OR !.a AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO. DATE a WORK TO HOUSE SEWER @ $3.001�/i OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT s 2 00 CHARGES AUTHORIZATION I TOTAL FEE ®© CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABO DESC ED EXISTING DWELLING APPROVALS TO THE PUBLIC��DAY' DATE INSPE O 5 SIGNATURE SIGNED THIS OF � 1 OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) i 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 ❑ IHEREBY CERTIFY THAV I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR LICENSED AS REQUIR Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THA M TH LEGAL OWNER OF, D INTEND TO DISCONNECT PLUG AND E-F IN, THE A DESC E PE)ID NTJ,pL PERTY. ABANDON HOUSE SEWER URE BACKFILL SEPTIC TANKS ❑ RMITTE SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK. M.O. SUPERVISING MECHANICAL ENGINEER CASH L.,;t,0 3 6 9 1 Qlv; GEC 2 7 1 0 ID 1 0.0 0�