HomeMy Public PortalAbout5103, 5105 DALEVIEW AVE_Sewer__ OE8
68 APPLICATION FOR PERMIT _
TansazD COUNTY OF LOS ANGELES
,SEWER-SEWAGE DISPOSAL,
DEPARTMENT. OF COUNTY ENGINEER- -
BUILDING AND SAFETY DIVISION : emLmnG _ ' �•
ADDRESS • Q l/ LV
IOHN A. LAMBIE, County EvgginIdi _
WILLIAM A. IENSEN, Supt of Building ;LOCALITY
AN
FOR APPLICANT TO FILL IN CROSS r
CROSS ST.
LEGAL
DESCRIPTION LOT NO.. % OWNER
BLOCK TRACT , MAIL
._O 'ADDRESS.
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
2ADDRESS
OF
DI DISTRICT NO. GROUP MAP PROCESS BY
LDINGS J V O Z I BK PG
TRACTOR ; Q ONt2
ION DAY 0 TE N0. Y� STATION DEPTH
STA
REGISTRATION ND. �L / �✓�/ COUNTY MANHOLE REFERENCE - UPPER -
LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO Ot
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.
PITS AND/OR DRAINFIELD @ .00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL. DRYW ELL @ .00
HOUSE SEWER CONNECTING TO P.C. O.
PRIVATE DISPOSAL SYSTEM @ .00 CO. . N0. JOB N O y.
CONNECT ADDITIONAL BLDG.OR P.
WORK TO HOUSE SEWER @ I.00 TRUNK PERMIT NO. ROAD PERMIT NO. U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT W
SEWER OR DISPOSAL SYSTEM @ T.00 PERMIT NO. {O{..
INDUSTRIAL V
- WASTE APPROVAL M
CHARGES 0
OWNER'S PERMIT S 2 0,,0..1 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE p V REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCIH -EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW
SIGNED THISDAY OF 1 NEW HOUSE SEWER
OWNER L+DING OR WORK
A
` OWNERS AGENT BUII
ADDRESS SEPTIC TANK,SEEP.PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT.1 HAVE.READ .THIS APPLICATION.., - - -.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑.
WITH ALL COUNTY OR DINANCES AND STATE LAW5 REGULATING ALTER,.REPAIR,SEWER OR
PLUMBING AND SEWERS. '-
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY RE S EKED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES C AND.STATE F, ABANDON HOUSE SEWER
DESCRIBED CALIFORNIA RESIDENT OR TL RM E LEGAL OF THE VE r BACKFILL SEPTIC TANKS Ll
SIGNATURE SEEP.:PITS)-❑ CESSPOOLS ❑
OF PERMITTE fR OF - ATION ROBERT A. WOOD
m.o. .CASH-. SUPERVISING MECHANICAL ENGINEER
LA[;o 1 5,0 8 JUL 12 1 0 u 5.0-0-