HomeMy Public PortalAbout9174 JAYLEE DR_Sewer_1/23/1962_sewer connection 76A642 -61 APPUCQT ON FOR PE o W l�
76A 642D
COUNTY OF LOS ANGELES S[�WER—SEVJ� � �D�p®�Q�
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. [(� OWNER
BLOCK TRACT ' MAIL
j ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY C� TEL. NO
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR Gawl
d
ADDRESS
CONNECTION DATA
CITY EL.NO. STATION DEPTH
[NATE MANHOLE REFERENC UPPER
REGISTRATION N0. � ❑ COUNTY LOWER
NO. I DESCRIPTION OF.WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $8.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ S2.00 Il
HOUSE SEWER CONNECTING TOP.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. R PERMIT N0.
WORK TO HOUSE SEWER @ S1.00
SEWER OR DISPOSAL SYSTEM ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO. V
INDUSTRIAL
WASTE AFF-Y,_H
CHARGES Z
OWNERS I PERMIT $ .21 OO CON CTION CHARGE FEE
AUTHORIZATION FToTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVAM SATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. ®
SIGNED THIS DAY OR 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL �����
OWNERS AGENT BUILDING.ORWORK (? �"t e(
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT tHAVE READ,_THIS APPLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTE
I HEREBY CERTIFY THAT 1 M PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY,LgQS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT R E BACKFILL SEPTIC TANKS ❑
SIGNATURE , SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE
VALIDATION ROBERT A. WOOD
cK. 0.0. CASH SUPERVISING MECHANICAL ENGINEER
(.h : 7 3 2 8 AN a 3 2 0 p . 3 .0 0