HomeMy Public PortalAbout10553 BOGUE ST_Sewer__ CEMB ,0-63
76A6426A642D APPLICAT'I N FOR PERM
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING i
JOHN A. LAMBIE, County Engineer ADDRESSWILLIAM A. JENSEN, Sup't o1 Building
LOCALITY
NEARESTFOR APPLICANT FILL INCR05B ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAILBLOCK TRACT ADD.NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY O.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
J BK PG
CONTRACTOR
ADDRESS ' CONNECTION DATA
CITY E
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TATION .�L�/ DEPTH
`p T �:z 77
CC/
TATE / ` UPPER
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE
N DESCRIPTIO OF WORK FEE TYPE OF CONNECTIONP.L. LENGTH FR �--'y
HOUSE SEWER CONNECTING TO ,.,� v Y. CURB M.L.TO P.L. •/
PUBLIC SEWER @ $5.00P.C.NO.(Y-U S
SEPTIC TANK,SEEPAGE PIT OR l=/ !
PITS AND/OR DRAINFIELD @ S10.00 CO.IMP. NO. JOB NO. O
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD LLL
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $5.00 p,
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z Oo
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE
'i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E STING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S IG NATU RE
SIGNED THIS F 19_ v [p
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT 1 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 [:1
I HEREBY CERTIFY H I AM PROPERLY REGISTERE AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REO ED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS POSAL SYSTEM
CALIFORNIA OR T 1 M THE LEGAL ER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH OV DESCRIBED R NTIAL PR RTY. ABANDON HOUSE SEWER
SIGNATURE SEPTIC TANKS ❑
OF PERMIT T SEEP.PIT( ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
7 CK. M.O. CASH
2 1 3 4% AUG 3 1 0 D7.0(� a