HomeMy Public PortalAbout10542 DANBURY ST_Sewer_7/31/1964_sewer connection 76961910-6376A64D APPLICATION FOR PERMIT
ESA
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 7 •-TQC L�''
JOHN A. LAMBIE, County Engineer ADDRESS `
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN GR.A. ST 0,/
GAL p
DESCRIPTION LOT ND. OWNER _ ��i $•�'V �IY
MAIL
BLOCK TRACT �� ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
//�f y /L BK PG
CONTRACTOR • Com. Y�y �p�` 5 Od /yam• V^� cj'�'
ADDRESS -/ vp I 'f CONNECTION DATA
CITY \•� • TEL. NO.�.��Z Q��/ STATION �' G DEPTH
❑ STATE MANHOLE REFERENCE r7 �VVLJJJ UPP
REGISTRATION NO. D /.+� ❑ COUNTY ' D �� YIMYF
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO 11 Y.
PU BLIC SEWER C $5.00 V✓
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. /' O
CO.I.E. NO. JOB 1,
PITS AND'OR ORA INFIELD C $10.00 V
HO U SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT RI IL41HT RECORD.INSTR,NO. DATE 1P
WORK TO HOUSE SEWER 0 $3.00 V
OVERFLOW SEEPAGE PIT,0RAINFIELO W
E%TN_.CESSPOOL,ORYWELL,MANHOLE @ SSO. 4
WIDENING (.`1
OR ST.
ALTER,REPAIR OR ABANDON HOUSE HWY. Z
$EWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 5� z 0
0
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE � e-O
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REI MBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECT OR 55GNATURE
SIGNED THIS DAY O 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.DRAINICLID T(Bt
HEREBY ACKNOWLEDGE THAT REC READ THIS APPLICATION AND/OR DftAINF1EL0
AND STATE THAT THE ORDINANCES
IS
CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRV WELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR w LTER. REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TXA AM THE LEGA WNER ANO INTEND TO
RESIDE IN, TME p
I.E. SIDEN]'IA PROPERTY. DISCONNECT PWG AND
C/�/
ABANDON HOUSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS ❑
OF PERMITTE EP.FIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
M.
CK. O. CASH SUPERVISING MECHANICAL ENGINEER
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