HomeMy Public PortalAbout9174 JAYLEE DR_Sewer_9/2/1955_sewer connection .8&6.663 3.55 APPLICATION - FOR PERMIT
DIVISION OF.BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING /
WM.J. FOX, COUNTY ENGINEER
fDDRESS / (�'�• 'Z,'
/ J
® CASSATT D. GRIFFIN, SUPT OF BUILDING OCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST: '!,d1 d
LEGAL gy / f �� •i
DESCRIPTION LOT NO. l/ - OWNER /
�j
BLOCK TRACT / q 3 � MAILj r
No OF BLDGS. ADDRESS
SIZE OFLOT NOW ON LOT � CITY TEL. N0.
USE OFi /; _
BUILDINGS _zZ L•GS_�5 DISTRICT NO. GROUPMAP
pF- SK PG
CONTRACTOR •� L.�sl 'x fo, ��,�, � s�
.ADDRESS � _ �� T.� _ CONNECTION DATA
CITY �� ^•� '"TEL. N0. t STATION DEPTH .
�{ 9�STATE _ MANHOLE REFERENCE -' s R'
REGISTRATIO 0 � '� ❑ COUNTY �� 1 %`% LOWER
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB P.L. M.L. TO P.L.
PUBLIC SEWER Q $ 3.50 -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR / P. C. N0.
WORK TO HOUSE SEWER 1.00 CO. IMP. N0. / �U / JOB NO.
ALTER OR REPAIR EXISTING
_SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC TANK, SEEPAGE PIT OR --
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL -
CESSPOOL- DRYWELL
WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
$ 1 00
OWNER'S PERMIT CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
�"
I HAVE THIS DATE .CONTRACTED WITH THE F[9REIN WAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER _ --
.11.lGic� {,� i4
SIGNED THIS_—DAY OF 1 0 19- NEW HOUSE SEWER
_ 1--
OWNER OR CONNECT ADDITIONAL v
OWNERS AGENT v\/ BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE TH T I HAW READ THIS APPLICATION ...CESSPOOL El DRYWELL❑ -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR. SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL'SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS-REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL �OW�NE,.,OF THE, A,OVE �ABANDON HOUSE SEWERDESCRIBEDRE I E TIA,PROPERTY:' 9 //� BACKFILL SEPTIC TANKS
� NAUEj �y ���uv4c, I r F"eZ SEEP. PIT(S) ❑ CESSPOOLS "tI -
OF PERMITTEE
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION - R.A.WOOD, CHIEF PLBG..INSPECTOR
i�] 0 7 4 9 L SEP P 4 .5
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