HomeMy Public PortalAbout5326ALESSANDRO AVE_Sewer ` 62
78A642D APPLICATION FOR PERMIT
A842D
COUNTY OF LOS ANGELES SEWER-SEWAGE DI
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �-
JOHN A LAMBIE County EngIn00[ ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL INi CROSS ST If
LEGAL
DESCRIPTION LOTN ( OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROC 9SED B
K Y
BUILDINGS '} P f
CONTRACTOR
ADDRESS CONNECTION DATA
O DEPTH
CITY
REGISTRATION NO COUNTY MANHOLE REFERENCE 6 LOWER
NO DESCRIPTION OF WORK F TYPE F NECTION NGTH FROM
HOUSE SEWER CONNECTING TO P L M L TO P
PUBLIC SEWER @ $5 00 �
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 51000
CO IMP NO .IOB NO �j
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD P MIT N07 ��
PRIVATE DISPOSAL SYSTEM @ S3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD NSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 4.
SEWER OR DISPOSAL SYSTEM @ $300 STAT ENCROACHMENT
` PER NO
D STRIAL
�w
OWNERS PERMIT s CHARGES
AUTHORIZATION I TOTAL FEE 1 [/ CONNECTION CHARGE FEE
I 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 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ElDRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND TEND TO DISCONNECT PLUG AND
RESIDE IN THE A E DESCRIB SID�1 AL PROP Y ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TTANKS El
OF PERMITTEE SEEP PIS) ElCESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L,Lu 0 1 9 9 SEP 13 1 1 D 2 5.0 OM
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