HomeMy Public PortalAbout6002 AVON AVE_Sewer_10/13/1965_house sewer connection to public sewer CE808 4 APPLICATION
PPA ICA ' ION FOR PERMIT
76A642D Pi IL. P'i tl itl If—IG IVI 1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ff. S
JOHN A. LAMBIE, County Engineer
ADDRESS '✓�,
WILLIAM A. JENSEN, Sup't o1 Building
FOR APPLI
CANT TO FILL IN -�-�
LEGAL
DESCRIPTION LOT NO. OWNER ✓L� ..� //'/
e;
�j MAIL ` •' ��"'ifl�.
BLOCK TRACT 2- �/ �� ADDRESS
j�J/
NOOF BLDGS.
.
SIZE OF LOT 010 NOW ON LOT CITY T.L. -NO. •.�/
BUILDINGS ../�1.L/� �'�/ C<�..- DISTRICT NO.1 GROUP MAP OCE55ED BY
USE OF
BK PG
CONTRACTOR r /J_
ADDRESS
CONNECTION DATA
CITY.., 'G(.(�i( TEL. N0. , �- STATION �J /`�, DEPTH
❑ STATE MANHOLE REFERENCEV (p UPPER
REGISTRATION NO. [I COUNTY, A, LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENG FROM /
HOUSE SEWER CONNECTING TO i Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR /�� P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. i JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00 lad
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD,INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
p.
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,M ANHOLE @ $5.00 {(J
ALTER,ROEPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING d
SEWER R DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT N
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 21 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWE APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF ✓ '���� 19�, "
OWNER OR - NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL /
ADDRESS /,� J �/" +�`�E "'�`��/X! 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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTI L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE PERMITTEE EE � BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) (:1CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
n, ' LAL076 3 5 81 OCT1. 3 1 0 A 7.0 Of, a