HomeMy Public PortalAbout9161 JAYLEE DR_Sewer_12/29/1969_sewer connection CE808 10-63
76A6420
APPLICATION
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION DUILDING
JOHN A. LAMBIE, County Engineer ADDRESS / Q�
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
. : r,,. .. ... _..._;.,. ..--.., NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL a
` BLOCK TRACT ADDRESS V/Y_
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY
USE OF
DISTRICTR NO. GROUP -BK MAP PG( PROCESSED BY
BUILDING V
CONTRACTOR r -7J
ADDRESS `J CONNECTION DATA
_ CI TEL. N �� STATION DEPTH
U STATEUPP
REGISTRATION NO. G'�{o�/E3 COUNTY
MANHOLE REFERENCE
REGISTRATION
V uze C
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER e° $5.00 Q
SEPTIC TANK,SEEPAGE PIT OR P.C.NO O
J
PITS AND/OR DRAINFIELD @ $10.00
CO.IMP. NO. OB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM Q $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE V`
WORK TO HOUSE SEWER @ $3.00 SV•
C OVERFLOW SEEPAGE PIT,DRAINFIELD LIJ
EXTN.,CESSPOOL,DRYWELL,MANHOL E C $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM 83.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 oD '
AUTHORIZATION TOTAL FEE hO CONNECTION CHARGE FEE
-1 HAVE 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 DATE INSPECTOR'S SI NATURE
SIGNED THIS DAAY019_ f.
OWNER OR //y7`"E�C NEW HOUSE SEWER �i'!j•
OWNERS AGENT (�.��[
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
IH
ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDI SN S AND STATE LAWS REGULATING
PLU MB ING AND SEWERS. CESSPOOL ❑ DRVWELL ❑
I HEREBY CERTC
M PROPE RL REGISTER AND�OR ALTER,REPAIR,SEWER OR
LICENSED_AS REOS ANGLES C UNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR LEG�'�'� R OF, AMD INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE BED RE I I L P OPE RTY. ABANDON HOUSE SEWER
SIGNATURE AC KFI LL SEPTIC TANKS ❑
OF PERMITTE SEEP,PITS) ❑ CESSPOOLS I�k%
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. ASH+
� r 66 DEC0 A 7.0 0,