HomeMy Public PortalAbout10539 BOGUE ST_Sewer__ f
6A6*' 10-63 A PPA 'C A TIO FOR PERMIT
7 6 A 6172 D /"i• L� /`� 9 II�
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 0�
JOHN A. LAMBIE, County Engineer ADDRESS 6,
WILLIAM A. JENSEN, Sup't of Building G +
LOCALITY
NEAREST
FOR APPLICANT O FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
07
MAIL
BLOCK TRACT ADDRE
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY
USE OF DISTRICT NO. GROUP MAP I PROCESSED BY
BUILDINGS 1 BK PG
CONTRACTOR
ADDRESS �/ CONNECTION
CITY TEL f STATION , .C\�7 DEPTH
ST TE �J d / UPPER)
MANHOLE REFERENCE
REGISTRATION NO. � ❑ COUNTY 7 ZKJ .-
/
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L� M.L.70 P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. / ,?
�
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. 7 �fL� O
N
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ S5.00 W
WIDENING
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST. h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ i o0
f AUTHORIZATION TOTAL FEE -7 Ao CONNECTION CHARGE FEE
A 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 R'S SIGNATURE
SIGNED THIS DAY OF 19_ 2_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT cl
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
1 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 ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERE AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RES4,WnD BY LOS ANGLES COUNTY AND TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR/HAT,4 AM THE LEGAL O R OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THY ABO E DESCRIBED RE TIA PRO TY. ABANDON HOUSE SEWER
SIGNATURE 7 BACKFILL SEPTIC TANKS E]OF PERMITT I PITS)
❑ CESSPOOLS ❑
VALIDATIOZD ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
U2 .1 3 6N-06 AUG 3 1 O D 7.00~