HomeMy Public PortalAbout5550ALESSANDRO AVE_Sewer (3) A
76ACE808 642D u
2/7,9 APPLICATION FOR PERMIT {J
76A 6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESSJOHN A LAMBIE COUNTY ENGINEERCOLEMAN W JENKINS SUPT OF BUILDING R APPLICANT TO FILL IN
(PRINT OR TYPE ONLY
LEGAL
DESCRIPTION LOT NO OWNER
r i' MAIL
BLOCK TRACT � ADDRESS
NO OF BLDGS r
SIZE OF LOT NOW =ON LOT CITY (,�� TEL NO u
USE OF
BUILDINGS A ' DISTRICTNO GROUP CLASS MAP PROCESSED BY
BK p
IVI �' ��
CONTRACTORlke a0
le
ADDRESS w CONNECTION DATA
3�
5 A ION / DEPTH
CITY TEL NO / p[ r
STATE /J���-� �" LIC MANHOLE REFERENCE �-
LICENSE NO CLASS LOWER
1
NO DESCRIPTION OF WORK FEE TYPE OF CONEC O °' LENGTH ROM .l
HOUSE SEWER CONNECTING TO Y J M L TO P L
PUBLIC SEWER @ $5 00
SEPTIC LANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD @ $1000
CO IMP NO JOB NO
HOUSESEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO // d
PRIVATE DISPOSAL SYSTEM S3 00 f!
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I wAIV[P [ASIMIMT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTNCESSPOOL DRYWELL MANHOLE 0 $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT V
t�'/?"1 PERMIT NO W
(fes INDUSTRIAL a
WASTE APPROVAL Z
OWNERS PERMIT $ CHARGES
AUTHORIZATION1 TOTAL FEE 130 &V
CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THI�_DAY OFA 1 19
OWNER ORNEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTICTANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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 ❑
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 THAT�1 v.4M THE LEGAL OWNER OF ANP INTEND O DISCONNECT PLUG AND
RESIDE IN THE VES E �11)� RESI�ENTPA PROPER Y ABANDON HOUSE SEWER I
SIGNATURE 1BACKFILL SEPTIC TANKS ❑OF PERMTTTE SEEP PIT(S) ❑ CESSPOOLS ❑
"/ VALIDATION JACK R ALLEN
CK M O CASH SUPERVISING MECHANICAL ENGINEER
L-4luo n 1 c 1 1 D 3 0 00,-
v