HomeMy Public PortalAbout5527ALESSANDRO AVE_Sewer 6A642 �D i2
7 - APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS P /�
WILLIAM A. IENSEN, Sup't of Building ITY
LOCALC.
NEAREST
FOR APPLICANT TO FILL IN CROSS BT
LEGAL r L- /N6 y,(
DESCRIPTION LOT NO f _ - OWNERI t'+ r //y U
/ /- _- MAIL -
BLOCK TRACT / _ q1 5ADDRESS
NO. OF BLDGS, L
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF c �`,.y
BUILDINGS__ S L l e Itc 4p'` DISTRICT NO.
I,l GROUP MAP PROCESSED BY
--.. BK PG
CONTRACTOR jyl� �/L! C."1 -•- "`. 75
.. .-_-^'1•`-- -_-. -_ 1�-__ lam_.:_ __--_-
ADDRESS V07 e e CONNECTION DATA
CITY TEL. NO 3 �!a STATION
/ } STATE MANHOLE REFERENCE
REGISTRATION NOL ',20e, j ❑ COUNTY ei '� ""' LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNE TI ! LENGTH FROM
_
HOUSE SEWER CONNECTING TO CIO Y. CUI2 P.L. M.L.TO P.L. 4
PUBLIC SEWER @ $5.00 11.• -- - F1
i. P.C.NO. VV
SEPTfC TANK.SEEPAGE PIT OR ') I JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.TMP. NO._ �.J ,. ,J,_,,,...- V
— - - - --------- — �'� ,._' - is
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG OR
-? -AFFIDAVIT wAIVEN EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
_-._.-R_ LD
__
._ -_. __
E
I OVERFLOW SEEPAGPIT._DAINFIE
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
-- -- --- -- --- --- ----- HWY..OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
j SEWEROR DISPOSAL SYSTEM _ @ $3.00 -`"------""-"--
STATE ENCROACHMENT
t j PERMIT NO. _
INDUSTRIAL ! _
WASTE APPROVAL
CHARGES
OWNERS PE_R_MIT _$;_ 2, 00 --
-� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE --
iHAVE 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
OWNER OR NEW HOUSE SEWER - -
OWNERS AGENT_,_,--"
CONNECTADDITIONAL
ADDRESS
BUILDING OR WORK
/
-- SEPTIC TANK,SEEP,PIT(5)
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 ❑
IHEREBY 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 OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A OVE[D EEV---RIBED REST N7 ; PROPERTY. ABANDON HOUSE SEWER
SIGNATURE 7i. � ,���� BACKFILL SEPTIC TANKS ❑
OF PERMTTTE K�(�. --- ----- SEEP.PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. - M.O. CASH SUPERVISING MECHANICAL ENGINEER
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