HomeMy Public PortalAbout5921 AVON AVE_Sewer_4/26/1965_sewer connection i
C A6420 -63 APPLICATION
IPPA ICA TION ICOR PERMIT 76A642D f'Y Y- l..11 !'9 Itl Jf-' G IV6 G -
COUNTY OF LOS ANGELES SEWER- SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION AveN A. LAMBIE, County Engineer 5921 Ne Avon t'A.
WILLIAM A. JENSEN, Sup't of Building San Gabriel
4FWebe-r
�ies ieFOR APPLICANT TO FILL IN LEGAL4DESCRIPTION LOT NO.
ADDRESS 592 6 N , T. C. Blvd. ,
BLOCK TRACT 29908 T
NO. OF SLDGS.
d T
SIZE OF LOT NOW ON LOT I CITY TEL. NO.
USE OF
BUILDINGS '. DISTRICT NO. GROUP MArP /p� PROCESSED BY
CONTRACTORHenr B.' Vega J ( tL <
ADDRESS 3245 No Ivar Ave . CONNECTION DATA .`
CITY 'TEL. NO, v't}' 0 004772 STATION Lr- DEPTH n
❑ STATE MANHOLE REFERENCE 1
REGISTRATIO ❑ COUNTY LOWER
` NO. GE F WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L' M.L.TO P.L.
PUBLIC SEWER @ $5.00 - °-
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AN DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Q�
PRIVATE DISPOSAL SYSTEM @ $3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
E XTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00
' HWY. OR ST.WIDENING h
ALTER.REPAIR OR ABANDON HOUSE
h' SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $1 2 00 CHARGES
i CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'IHAVE 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
ALS DATE INSPECTOR'S SIGNATURE
4 SIGNED THIS DAY OF 19_ 3
OWNER OR NEW HOUSE SEWER
OWNERS AGENT New CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PITS)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING F-1PLUMBING AND SEWERS. CESSPOOL F1DRYWELL
I HEREBY CERTIFY_T. AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RE Aft-REE BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O T I AM HE LEGAL OW-fV R OF, A D 1 TEND TO DISCONNECT PLUG AND
RESIDE IN, Ti,E_ ROVE DESCRIBED RES.I TIAL P P TY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT ❑
SEEP.PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
- CASH
7.0
_�i JJ