HomeMy Public PortalAbout9030 ACASO DR_Sewer_5/14/1958_sewer connection 11.555 E!9'D-�
S 863 APPLICATION FOR PERMIT' 1
S&E
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County Of Los Angeles BUILDING �f
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS s )dr
® CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY 1
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO. r'
MAIL /
BLOCK TRACT �� ADDRESS •`—�
14
NO.OF BLDGS. CITY TEL. NO. r
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS J /• BK PG
CONTRACTOR / 73
CONNECTION DATA
ADDRESS
STATION DEPTH
CITY ,i TEL. N0. G - - -
MANHOLE REFERENC
®I-5 ATE _ �� o WER
REGISTRATIO N0. ❑ COUNTY O
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR �Dl� 5A_A11rf1rY S�0I��
PITS AND/OR DRAINFIELD tai $3.00 / f'r Y6'
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C..NO.
r
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO _
PRIVATE DISPOSAL SYSTEM @ $1.00JELLING
TRUNK D PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROWORK TO HOUSE SEWER @ $1.00PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSEINDUST L
SEWER ORDISPOSAL SYSTEM c@ $1.00WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIAPPROVALS DATE INSPECTO IGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTTO THE PUBLIC SEWER. - NEW HOUSE SEWERSIGNED THISDAY OF CONNECT ADDITIONAL 6ZOWNER OR BUILDING OR WORKOWNERS AGENT �� " SEPTIC TANK,SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
j I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT.,I AM THE EG OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT L'�PROP TY. BACKFILL SEPTIC TANKS❑ _-_�
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS _ - JL-�--
OF PERMITTEE
JOHN A. LAMBIE. COUNT NGINEER VALIDATION ROBERT A. WOOD, CHIEF PLEIG. INSPECTOR
N.O. . CASH - - _ .