HomeMy Public PortalAbout9174 JAYLEE DR_Sewer_10/4/1972_sewer repair 76A 642D-CE808-10-71 APPLICATION
IICATION FOR PERMIT
EEMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ffc
/ /ADDRESS
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FOR APPLICANT TO FILL IRI
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL '712el
V
BLOCK TRACT ADDRESS
SIZE OF LOT -NOW OON LOT CIT &- TEL. NO.
USE OF
BUILDINGS ' DISTRICTN NO. GROUP MAP PROCESSED BY
JAB K P G
CONTRACTOR �/j ''--�Q�• I s O
ADDRESS. / .�- `.�j •_ CONNECTION DATA
CITY TEL. NO. / STATION DEPTH
STATELIC _ UPPER
LICENSE NO,:
! CLASS MANHOLE REFERENCE LOWER
No. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P:L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
P.C.NO.
SEPTIC'TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I wAIVII -IAIIIINT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. @ $5.00 O
TER.REPAIR OR ABANDON HOUSE Jah HWY.OR ST.WIDENING I—
SEWER OR DISPOSAL SYSTEM @ $3.00 (•��+ STATE ENCROACHMENT u
MANHOLE @ $7.00 PERMIT-NO. d
INDUSTRIAL N
WASTE APPROVAL z
OWNERS PERMIT S 3 OD CHARGES
AUTHORIZATION /
TOTAL FEE / Gp0 CONNECTION CHARGE FEE
41
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM P RLY RE STERED D/OR ,.REPAIR.SEWER OR )
LICENSED AS REQUIRED BY LOS NG S COU Y AND TATE OF AGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM TH EG Ne
OF. A TEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESC IBED ESID IAL P RTY. ABANDON HOUSE SEWER
SIGNATURE [:1OF PERMITTEE BACKFI L SEPTIC TANKS
SEEP.P T`(S) `�SSPOOLS ❑
VALIDATION CK. M.O. CASH
L 9082y DU 4 1 0 0 6.00