HomeMy Public PortalAbout10547 BOGUE ST_Sewer__ C E108/0-63 8fi4, 0-63 \' APPLI CAT( FOR PERM 1
COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS _
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL 6/
BLOCK TRACT ® ADDRE v /I
Nf5. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACT
ADDRESS CONNECTION DATA
CITY TF
/
STATION -- DEPTH
STATE /, UPPER
REGISTRATION NO. COUNTY MANHOLE REFERENCE �j.
NO. DESCRIPTION OF WORK FEETYPE OF CONNELENGTH FROM
HOUSE SEWER CONNECTING TO Y. CTIO P.L.CURB M.L.TO P.L. / / '
PUBLIC SEWER @ $5.00 (/(/ a
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. /j O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. l/V V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 9x
PRIVATE DISPOSAL SYSTEM @ S3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD LLL
E X TN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING yHy
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT 6
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z 00
AUTHORIZATION TOTAL FEE 7CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EVSTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF —19— 'S-G
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY AT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REO D BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT 1 AM THE LEGAL O ER O , AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, T OV DESCRIBED RE TI PROP RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM( SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
j .2 1 3 5m AUG 3 1 0 D 7.00