HomeMy Public PortalAbout5720ALESSANDRO AVE_Sewer v �
76A 642D -CE808 -10-71 APPLI CATI N FOR P MIT
COUNTY OF LOS ANGELES SEWER—S AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRE7,Z no 4er+ -yXw'v/npleV)
LOCALITY r `I/
FOR APPLICANT TO FILL IN NEAREST
GROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT __ADDRESS�C ��D
SIZE OF LOT NOWOON LOTS CITYr1„_--f/,VlC'
USE OF
BUILDINGS DISTRICT N0. GROUP MAP OCE SSED BY
Jr
K PG
•J
CONTRACTOR ��.Q8 / L '--/ 3
ADDRESS _ CONNECTIONN DATA
CITY TEL. NO. STATION ( DEPTH
STATE LIC UPPER
LICENSE
MANHOLE REFERENCE
LICENSE NO:: CLASS f D� � I �L�YMCR'
NO. -DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. �CU_R�''B�_„_ P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK.SEEPAGE PIT OR / P.C.NO,
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Y/AIVER "EASEMENT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD O
�
EXT N..CESSPOOL.DRYWELL. @ $5.00 HWY. OR ST.WIDENING �/y�� (//��
A' 8..REPAIR OirM'1s}!IlD9N HOUSE
SEWER OR4/PF-9*AL SYSTEM $3.00 6 STATE ENCROACHMENT 767 W
MANHOLE $7 00 PERMIT NO. CL
INDUSTRIAL N
WASTE APPROVAL z
OWNERS PERMIT s 3 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE v
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
L
COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
AND SEWERS. CESSPOOL Cl DRYWELL
Y CERTIFY THAT i AM PROPERLY REGISTERED AND/OR A'L,�,R:`REPAIR.SEWER OR
AS REOUIR D BY LOS ANGLES COUNTY AND STATE OF S,EWA_GE DY$PO$%C-,`�L..S,Y.SFET71 �- Cf !/
IA OR THA I AM THE LEGAL OWNER OF'AND INTEND TO DISCONNECT PLUG AND I
, THE A V DESCRIBED RESID [CTIA PROPERTY. ABANDON HOUSE SEWER
E (/ BACKFILL SEPTIC TANKS ❑
MITT SEEP.PIT(S) ❑ CESSPOOLS ❑
V NIDATION CK. M.O. CASH
8726-'FE6 191i D 6.0VA .,