HomeMy Public PortalAbout10531 BOGUE ST_Sewer__ 2�
CE80�1110-63 APPLICATION FOR PERM
76A642D
COUNTY OF LOS ANGELES SEW R—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O� �'
JOHN A. LAMBIE, County Engineer ' nDOREss
WILLIAM A. JENSEN, Sup't of Building..
LOCALITY
NEAREST
FOR APPLICANT TO LL IN CROSS 5T
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT a A
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRALTO �-
ADDRESS]? CONNECTION DATA�,rr
CITY TEL
STATION / z DEPTH
_ /
If —
STATE ///��� UPPER
MANHOLE REFERENCE /9 �' �,
REGISTRATION NO COUNTY / / _
NO DESCRIPTION ORK FEE TYPE OF CONNECTION P L LENGTH FR M� `
HOUSE SEWER CONNECTING TO /y Y CURB ML TO P IL
aO
PUBLIC SEWER @ $5 00 D PC
4.
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO. JOB NO. O
PITS AND/OR DRAINFIELD @ $10 o0 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 w
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR NO DATE O
WORK TO HOUSE SEWER @ $3 00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD l!J
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $500 d
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING (n
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
OWNERS PERMIT $ 2 00
WASTE APPROVAL
CHARGES
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AUTHORIZATION TOTAL FEE ! " CONNECTION CHARGE FEE
I HAVE 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 Q NEW HOUSE SEWER
OWNERS AGENT s=�f// fI
CONNECT ADDITIONAL (11
ADDRESS BUILDING OR WORK
SEPTIC TANKSEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR ORAI NFIELD
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 THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A E ESCRIBED RESID NTIAL PRO RTY ABANDON HOUSE SEWER
SIGNATURE KFILL SEPTIC TANKS ❑
OF PERMITT ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATIOIA.
ROBERT A. WOOD
CK M O SUPERVISING MECHANICAL ENGINEER
H
2 1 3 8% AUG 3 1 0 0 7.0 ON rQ