HomeMy Public PortalAbout5620 CAMBURY AVE_Sewer__ DEBDB 3-64 • - APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADORE
WILLIAM A- JENSEN, Sup't of Buildiag
LOCALITY
NEAREST �
FOR APPLICANT TO FILL IN ORDBS 5T.
LEGAL
[BLOCK
ESCRIPTION LOT NO. OWNER
r MAIL
TRACT JJ ADORERS /yyq/� NO. OF pGS2E OF LOT � L NOW ON LOT ( CITYTEL. NO. 3if
3E °F gyp///)UILDINGS OISTRiCTN . GROUP MAP PROCESSED BY
SIC BK PIS /f / - �a
CONTRACTOR /{51 i �_ ♦/ 1,' / � 4 ' /�. C(/
ADDRESS 5' 4 9p rvr<`�n-+L.� � (� CONNECTION DATA
CITY TEL. NO. 1-,�O 0 STATION DEPTH
R STATE UPPER
REGISTRATION NO. LJ MANHOLE REFERENCE COUNTY 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 @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO. O
PITS AND/°R ORA INFIELD @ 510.00
NO U SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, V
PRIVATE DISPOSAL SYSTEM $3.00
CONN E C T ADDITI ONAL AFFIDAVIT wAlYu uu
zlRi RECORD.INSTR,NO. DATE �•
I WORK TO HOUSE SEWER ® 53.00 pD O
OVERFLOW SEEPAGE PIT.DRAINFI ELO
EXTN..CESSPOOL,DRYWELL.MANH O LES $5.°0
ALTER.REPAIROR ABANDON HOUSE HWT.OR ST.WIDENING - a
SEWER OR°ISPOSAL SYSTEM ® 53.00 STATE ENCROACHMENT p z
PERMIT NO. v
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS pEAMIT s 2 00
AUTHORIZATION I TOTAL FEE M D B CONNECTION CHARGE FEE
Y 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 INSP TO R'S SIGNATURE
SIGNED THIS DAV OF 19_
OWNEROR NEW HOUSE SEWER
OWNERS AGENTCONNECT ADDITIONAL
F. L°I NO OR WORK
ADDRESS
SEPTIC TANK.GRAI SEEP.PIT PIT(S)
1 HEREBY THAT
THE ABO THAT 1 HAVE READ THIS APPLICATION AND/OR DRpINF1ELD
AN VWITH
STATE THAT THE ABOVE IS CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ °RYW ELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REO.I.ED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE L GAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE SC RI RE51 NTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
zZ cK. D. SUPERVISING MECHANICAL ENGINEER
M. cpsH
444 '8 APR26 I O D 5.0.0-