HomeMy Public PortalAbout5546ALESSANDRO AVE_Sewer 642D 2/170
76A APPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER noDREss
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY 4 �-$.^
FOR APPLICANT TO FILL IN NEAREST
CROSS ST !'O
(PRINT O YPE NLY)
LEGAL /-
DESCRIPTION LOT NO G OWNER
MAIL ]Di
BLOCK TRACT ADDRESSNO OF BLDGS
SIZE OF LOT NOW ON LOT CITY h TEL NOUSE OF
BUILDINGS r DISTRICTND GROUP CLASS BK MAP P PR
't
CONTRACTOR �N ���
ADDRESSCONNECTION DATA y�
CITY
TEL
NO 33 5 3-3 If ION Z DEPTH ///
STATE LIC MANHOLE REFERENCE ! !/
LICENSE NO CLASS 0- L LOWER
NO DESCRIPTION OF WORK FEE TYP OFC NNEC LENGTH FROM
HOUSE SEWER CONNECTING TO Y ML TO P L �
PUBLIC SEWER @ $5 00
C NO
SEPTIC TANK SEEPAGE PIT OR
J
PITS AND/OR DRAINFIELD $1000
CO IMP NO (.� OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO %�}�
PRIVATE DISPOSAL SYSTEM @ S3 00 / V CL
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER CASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELD OC
EXTN CESSPOOL DRYWELL MANHOLE @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL ,YSTEM @ $3 00 STATE ENCROACHMENT V
W
PERMIT NO
INDUSTRIAL N
WASTE APPROVAL Z
OWNER S PERMIT a
CONNECTION CHARGE FEE CHARGES
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 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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
LICEN SEDAS 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 �QfYV SC RJD�R $IBE NTIAC PROPERTABANDON HOUSE SEWER
SIGNATURE QVC/
OF PERMtTT EE Y BACKFILL SEPTIC TANKS ❑
P PITS) ❑ CESSPOOLS ❑
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
PCK M O CASH
� � � `�N 1 11D 3000-
_ �-_ �