HomeMy Public PortalAbout5330ALESSANDRO AVE_Sewer ,D 82
76A642D APPLICATION FOR PERMI
78A84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
g
JOHN A LAMBIE County Enmeer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN r CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS 71
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP y� PROCES BY
CONTRACTOR
ADDRESS CONNECTION DATA
TION DEPTH
CITY TEL NO
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK I FEETYPE F �6N�EC'TION L TH FROM
HOUSE SEWER CONNECTING TO Y ' P L M L TOP o`
PUBLIC SEWER @ $5 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 31000 CO IMP NO JOB
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO R D PERMIT N i
PRIVATE DISPOSAL SYSTEM @ 53 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W411111 EASEMENT RE RD ID
NSTR NO ATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXT N CESSPOOL DRYWELL MANHOLE @ E5 00 r
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCR CHMENT
/ PERMIT NO
INDUST
WASTE A O L
O RAS PERMIT s
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE ` 0'7z:>
1HAVE 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 I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER O AND INT TO DISCONNECT PLUG AND
RESIDE IN THE ABO E IB ENTIA ROPERTY ABANDON HOUSE SEWER
SIGNATURE BA FILL SEPTIC TANKS ❑
OF PERMITTEE P PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LI ,o0202G SEPI 311 D 25.00~ 4