HomeMy Public PortalAbout5546ALESSANDRO AVE_Sewer (2) 2"°
76A 642D APPLICATION FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FN
DING
JOHN A LAMBIE COUNTY ENGINEER RESS
COLEMAN W JENKINS SUP T OF BUILDING
ALITY
R APPLICANT TO FILL IN REST
SS ST
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLOGS
SIZE OF LOT NOW ON LOT CITY A TEL NO
USE OF
BUILDINGS DISTRICT NO I GRO/UP CLASS BK MAP p PROCESSED BY
E /J %. �
CONTRALTO Le
JJJ
ADDRESS CONNECTION DATA
CITY NO
�V Q STATION DEPTH
STATE �' LIC UPPER
LICENSE NO CLASS MANHOLE REFERENC!11
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIall,. LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB ML TOP L
PUBLIC SEWER @ 35 00 P C NO
SEPTIC LANK SEEPAGE PIT OR CO IMP NO NO
PITS AND/OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERM O >"
PRIVATE DISPOSAL SYSTEM S3 00 d
CONNECT ADDITIONAL-115�- ,y_�� AFFIDAVIT WAIVEN EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ 43 00 !/-
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ S500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Q
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT V
PERMIT NO E W
INDUSTRIAL a
WASTE APPROVAL --� h
Z
OWNER S PERMIT s F
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO COVNECT 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
ADDRESS BUILDING OR WORK /
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
1 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 O ER OF ND INTEND TO DISCONNECT PLUG AND
RESIDE IN TH RtS1 N IAL E Ty ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE Al SEEP PIT(S) ❑ CESSPOOLS ❑
11 .
U
l A 'PION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK CASH
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