HomeMy Public PortalAbout5550ALESSANDRO AVE_Sewer (2) 642D 2/70
76A APPLICATION FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY
R APPLICANT TO FILL IN NEAREST ,
CROSS ST
(PRINT OR TYPE ONLY)
,
LEGAL
LOT NO OWNER
MAIL
TRACT ADDRESSO n 1
NO OF BLDGS
NOW ON LOT I CITY TEL NO
DISTR ICTNO GROUP CLASS MAP PROCESSED BY
Lf / BK p
CONTRACTOR
ADDRESS CONNECTION DATA
STATION DEPTH
CIT TEL NO
UPPER
STATE LIC MANHOLE REFERENC
LICENSE NO CLASS LOWER
NO DE8YCRIPIriON OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL
ML TOP L
PUBLIC SEWER ® $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR B NO
PITS AND/OR DRAINFIELD @ 31000 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PE MIT NO
PRIVATE DISPOSAL SYSTEM @ 53 00 Q.
CONNECT ADDITIONAL AFFIDAVIT I WAIY[■ [AS[MEMT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300 �" V
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ f5 00 DC
HWY OR ST WIDENING O
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM S300 STATE ENCROACHMENT
PERMIT NO �.fi2 IJ.1
INDUSTRIAL '+'�',�'�� d
WASTE APPROVAL �' .�-7 Z_
CHARGE
OWNER S PERMIT s 00
AUTHORIZATION TOTAL PEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO COV NECT 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)
I 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
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH T AM TH L GAL OWNER OF A D INTEND TO DISCONNECT PLUG AND
RESIDE IN Tt�E O& V CIf ES �NTI L �' R Y ABANDON HOUSE SEWER
�b(( ✓✓✓✓✓1 /
SIGNATURE ~ BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE SEEP PIT(SEPTIC
❑ CESSPOOLS ❑
ALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L'�%O rD rl �;, 2 4 1 D 6 00-