HomeMy Public PortalAbout10532 BOGUE ST_Sewer__ C E804'10-63
76A6426A642D APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL '�JI
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �`
JOHN A. LAMBIE, County Engineer ADDRESS / (�tI V(/
WILLIAM A. JENSEN, Sup't of Building
LOCALITY �
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL
DESCRIPTION LOT NO
j r
MAIL /
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
.. BK PG
CONTRACTOR
ADDRESS ' /7/-/-
CONNECTION DATA
CITY ' STATION � DEPTH
V ❑ COUNTSTATE Y MANHOLE REFERENCE /Q UPR
REGISTRATION NO ,2�
NO. [DESCRIPTION OF WOR FEE TYPE OF CONNECTION LENGTH F OM
HOUSE SEWER CONNECTING TO ^ ,, Y CURB L M.L TOP L. �r D
PUBLIC SEWER C $5 00 d'�f P C.NO O
SEPTIC TANK,SEEPAGE PIT OR JOB NO. '7
PITS AND/OR DRAINFIELD C $10 oo CO.IMP. NO ( 6 U
HOUSE SEWER CONNECTING TO -' TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $300 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT 1AIVE1 EASEMENT RECORD INSTR 0
NO DATE
WORK TO HOUSE SEWER @ $300 U
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00 a
ALTER.REPAIR OR ABANDON HOUSE
HWY OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIST NG DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S ;GNATURE
SIGNED THIS t,��YYF_ 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERL REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLE OUNTY NO TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR I M THE LEGAL NER O AND TEND TO DISCONNECT PLUG AND
RESIDE IN, TOR
ABOVE ESCRIBED R ID NTIA ROP TY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
C M o ASH SUPERVISING MECHANICAL ENGINEER
2 14 0 AUG 3 1 0 0
7.0 0