HomeMy Public PortalAbout9634 CRAIGLEE ST_Sewer__ [EBDB 12-BB
76A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE D POSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 3
a L/
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
NEAREST /�
FOR APPLICANT TO FILL IN CROSS ST. / e
LEGAL G/
DESCRIPTION LOT NO. OWNER
MAIL E
BLOCK TRACT ADDRESS
IN 0' OF OLD GS.
SIZE OF LOT NOW ON LOT CITY • TEL. NO.
USE OF
BUILDINGS DISTRICT NO. OUP MAP PROCESSED BY
J
CONTRACTOR
ADDREss 4t
/` r CONNECTION DATA
CITY `. (�alt u /* TEL. NO./ - of/776 STATION y_ 1 DEPTH
STATE (//_ /� IC MANHOLE REFERENCES �•J UPPER
LICENSE NO, r & v CLASS "'
NO. I DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L._) M.L.TO P.L.
PUBLIC SEWER (a $5.00 V
SEPTIC TANK.SEEPAGE PIT OR J� P.C.NO.
PITS AND/OR DRAINFIELD @ 60.00 CO.IMP.NO. / JOB NO.
HOUSE SEWER CONNECTING TO >_
PRIVATE DISPOSAL SYSTEM @ S3.00 TRUNK PERMIT NO. ROAD PERMIT NO. CL
O
CONNECT ADDITIONAL BLDG,OR AFFIDAV-1 WAIVER EASEMENT RECORD,INSTR.NO. DATE (,
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESS POOL.DRYWELL.MANHOLE @ $5.00
HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE U
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT cl-
PERMIT NO. C./)
Z
- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE 760 CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP.PITS)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
LCLALII.RN
AND SEWERS. CESSPOOL ❑ DRYWELL ❑
CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
OR THAT 1 AM THE LEGAL.OWNER OF, AND INTEND TO ISCONNECT PLUG AND
THE ABOVE DE$CR BED DENTIAL PROPERTY. gBANDON HOUSE SEWER
BACKFILL SEPTIC TANKSTTEE ❑
SEEP.PIT(S) ❑ CESSPOOLS
(�`M.O. CASH ATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.
I pr., 6 2 4 L cc_'3 AU610 1 0 0 7.0 0=