HomeMy Public PortalAbout6007 AVON AVE_Sewer_10/13/1965_ 3 64
76A64 2D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS C/`1✓V 1��1
WILLIAM A JENSEN Sup t of Bu>ldmig
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `Ross ST
LEGAL
DESCRIPTION LOT NO17
OWN ✓
�J MAIL
BLOCK TRACT 9pC ADDR
SIZE OF LOT SD 11( NO OFN LOTS / CIT NO �r
USE OF DISTRICT NO ROUP MAP OCESSED BY
BUILDINGS
BK PG
CONTRACT y V
ADDRE S CONNECTION DATA
CI , TEL NO STATION {' DEPTH
S ATE / UPPE
MANHOLE REFERENCE
REGISTRA74ON NO ElCOUNTY f� LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F46m, /
HOUSE SEWER CONNECTING TO Y CURB P L ML TOPIL
PUBLIC SEWER @ ss 00
SEPTIC TANK SEEPAGE PIT OR CO IMP NO /3 JOB NO Q.
PITS ANO/OR DRAINFIELD @ $1000 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ E3 00 O
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ ES 00 W
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 4.
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT N
PERMIT NO z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT 3 ZI 00 CHARGES
AUTHORIZATION i TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DE BED EXISTING DWELLING
TO THE PUBLIC SEWER !� /'� APPROVALS DATE INSPEC3OR S SIGNATURE
SIGNED THIS D 7 19L�`
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I AVE 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 [I DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DE CRI BERESID TIAL PROP RTY ABANDON HOUSE SEWER
SIGNATURE ►'7VJ�^.�r1�/I BACKFILL SEPTIC TANKS E]OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
ROBERT A WOOD
( -VALIDATION
K M 0 CASH SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LACO6 3 5 6%no OCT 13 1 0 A 7.0 Q~