HomeMy Public PortalAbout5106 DALEVIEW AVE_Sewer__ 1, - D
$aE6APPLICATION FOR ,PERMIT 1
GDMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engtneer
County of Los Angeles BUILDING AA
.JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT O. GRIFFIN, SUPT OF BUILDING LOCALITY
CO+^
IS
FOR APPLICANT TO FILL IN caORSS ST. I(�^
LEGAL OWNER
DESCRIPTION LOT N0.
40 ), o MAIL
BLOCK TRACT ADDRESS
N0.OF SLOGS. CITY TEL. N0.
SIZE OF LOT L NOW ON LOT
USE OF DISTRICT N0. GROUP MAP
BUILDINGS /+� /'�
CONTRACTOR P ) 1
ADDRESS 7.7 �(• T X o.n"*--Cb CONNECTION DATA
STATION DEPTH
CITY TEL. N0. Z MANHOLE REFERENCE -
REGISTRATION N0. {' Cs ❑ STATE LOWER
�'1� [I COUNTY -1,
Tz
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
P UBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD @ $3.00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. N0. J S lOB N0.
EKTN..CESSPOOL,DRYWELL,MAN HOLE @ $ 2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0, ROAD PERMIT N0.
e� CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 Oo PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00 '
AUTHORIZATION TOTAL FEE v� REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOWSSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO-THE PUBLIC SEWER. NEW HOUSE SEWER
e
SIGNED THIS-. DAY OF 19 CONNECTADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ` DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF 4ABANDON HOUSE SEWER_
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP. PIT(S) C1CESSPOOLS❑
,�7 D/ ' _
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDA'T'ION . ROBERT A.WOOD. CHIEF PLBG. INSPECTOR
K tl.0. CASH
L&O'. 5Zn APR 23 4 A . 2DO .A.
Ga.