HomeMy Public PortalAbout9656 CRAIGLEE ST_Sewer__ 6A64 10-63 APPLICATION FOR PERMI 8-
76A642D i`Y
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, Supt of Building
LOCALITY
NEAREST
FOR APP CANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N OWNER
MAIL
BLOCK TRACT ADDRESS
BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. .NO.
USE OF DISTRICT NO. GROUP MAP PROCESS BY
BUILDINGS
�'0 BK PG
CONTRACTOR � .�
ADDRESS CONNECTION ATA
CITY TEL. NO. T ION D�„�a 7TH {�
❑ STATE y~/'` (�
MANHOLE REFERENCE P
REGISTRATION NO. ❑ COUNTY. �`--a LOWER
NO. DESCRIPTIO OFWOIRK PtE ON 7NGTH FOM
HOUSE SEWER CONNECTING TO (! v V. �e P.L. M.L.TO P.LR. `1 }
PUBLIC SEWER @ $5.00 p,
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT V
PRIVATE DISPOSAL SYSTEM @ $3.00 > F// (/J�(j'
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE Q
WORK TO HOUSE SEWER @ 83.00
OVERFLOW SEEPAGE PIT,DRAINFIELD 10 1 W
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY. O ID N
ALTER.REPAIR OR ABANDON HOUSE to
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCRO MENT
i PERMIT NO.
INDUSTRIAL C
WASTE APPROVA
CHARGES
OWNER'S PE $ 2 Oo
AUTHORIZATION TOT L FEE .rV CONNECTION CHARGE FEE
A HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING .
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE'
SIGNED THIS DAY OF 19_ ./.,-���.✓'�"Q�- -<�-.¢/j
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL V V
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS A GLES COUNTY AND 5 TE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT T LE AL ER OF, D I T ND TO ', DISCONNECT PLUG AND
RESIDE IN, THE AB E d NTI OPE T ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
,s; LACO 1 -9 9 4zav' JUL 3j 0 1 0 D 7.0 0- IN
F
CE808 10-63
76A642D APPLICATION FOR I— R IV➢ L
COUNTY OF LOS ANGELES SEWER-SEW GE DISPOSA
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 APP ICANT T9 FILL IN CRISIS BT.
LEGAL
DESCRIPTION LOT N OWNER
MAIL
BLOCK TRACT ADDRESS
N6. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
DIS
USE OF TRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTORO Z-1
ADDRESS CONNECTION DATA
CITY, TEL. NO. • ION DEPTH.. ® /
STATE MANHOLE REFERENC !
REGISTRATION NO. ❑ COUNTY j LOWER)
NO. DESCRIPTI OF WORK FEE TYPE OF CO £ 10 s NGTH FROM
/ HOUSE SEWER CONNECTING TO TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
CO,IMP. NO. .108 NO.
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N l
PRIVATE DISPOSAL SYSTEM @ $3.00 _ ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEN I EASEM T RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT;DRAINFIELD �_j Uj
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 a
ALTER.REPAIR OR ABANDON HOUSE HWY. ST.WI E I GIA) U)SEWER OR DISPOSAL S)'STF„M @ $3.00 STATE E CROA HMENT `�
PERMIT NO. ~
N A
WASTE APPROVAL
OWNERS PERMIT
AUTHORIZATION TOTAL FEE � . CONNECTION CHARGE FEE.
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED VCON- REIMBURSEMENT FEE
TRACTOR TO 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 I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
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 WLOS
PERLY REGISTERED AND/OR '- ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRLES COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA WNE F, INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE VD L P O TV. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMI7T : SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH .
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