HomeMy Public PortalAbout5502ALESSANDRO AVE_Sewer 7SA642D F u APPLICATION FOR PERMIT
CE808 8_'pt
ff// Y LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING k �`
JOHN A.'LAMBIE, Countx Engineer ADDRESS
on�r
CASSATT D. GRIFFIN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL CROSS ST.
LEGAL WNER Q
DESCRIPTION LOT N0.
BLOCK TRACT MAIL
4 ®!V /�O4/ C ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOTq
CITY L. NO.
USE OF
BUILDINGS �^ CYrY1/fDISTRICT N0. GROUP MAP PROCESSED B
I BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL.N0. STATION LC. - DEPTH
REGISTRATION NO. MANHOLE REFERENCE
NO. DESCRIPTION OF WO K FEHOUSE SEWER CONNECTING TO ��
PUBLIC SEWER @ $3.00 13 TYPE OF CONNECTION LENGTH FROM_ �
[—�
SEPTIC TANK,SEEPAGE PIT OR Y.
CURB P.Le M.L.
TO P.L. c3
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO yy P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTSEWER OREPAIR SPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE `I I t., REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE IINGAMED DWELLIING APPROVALS !DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR /)� / CONNECT ADDITIONAL
OWNERS AGENT "f „J BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE 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 SYSTEM
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ORS DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAP PERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PITS) ❑ CESSPOOLS ❑
OF PERMITTE J
®' VALIDATION"N. ROBERT A. WOOD
C& M.0. CASH/ SUPERVISING MECHANICAL ENGINEER
L"iC 8 7 3 1 SO APR 4. 1 0 A _ 5.0 0