HomeMy Public PortalAbout10560 BOGUE ST_Sewer__ 0'-63
76A642-D APPLICATION FOR PER IT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 0 ^
JOHN A. LAMBIE, County Engineer ADDRESS G
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
G7
ST
LEGAL
DESCRIPTION LOT,INO 01OWNER
MAIL ,��
BLOCK TRACT a ADDRESS /VO I
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDING
CONTRACTOR v OC1 ���• _�
ADDRESS CONNECTION DATA
�q STATION /�--�/ DEPTH
CITY TEL 6� KJ c!J
STATE
REGISTRATION NO � 02� ❑ COUNTY MANHOLE REFERENCE / i LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION !!! _ LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P,L. M.L TO P L
PUBLIC SEWER @ $5 00O.
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. •� ''
PITS ANOlOR DRAINFIELD @ S10.00 CO IMP. NO. JOB NO (Q O O
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3 00 w
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR NO DATE O
WORK TO HOUSE SEWER @ S300 V
OVERFLOW SEEPAGE PIT.DRAINFIELD L7.1
EXTN,CESSPOOL,DRYWELL,MANHOLE @ SS 00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE 7 /O�/1 CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SIG ATURE
SIGNED THIS D Y 19_
OWNER OR NEW HOUSE SEWER ,f _
OWNERS AGENT CONNECT ADDITIONAL v
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP,PIT(5)
I 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 I AM PROPERLY REGISTERED A DOR ALTER,REPAIR,SEWER OR
LICENSED AS REO D BY LOS ANGLES COUJ�{TY AN ST E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T AM THE LEGAL OWN F, A IN ND TO DISCONNECT PLUG AND
RESIDE IN TH BO DESCRIBED RESID L P R ABAND SE SEWER
L�01`
NATURE '
PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATIO�1 ROBERT A. WOOD
CK M.O. CASH
l(!, ) SUPERVISING MECHANICAL ENGINEER
O. 1 4 5 AUG 3 1 0 D 7.0 0- Q