HomeMy Public PortalAbout5112 DALEVIEW AVE_Sewer__ 2-
S&E-03`11-5H APPLICATI OIl1 FOR PER T -
DIVISION OF BUILDING AND SAFETY SEWER-S WAGE DISPOSAL.
Department of County Engineer County of Los Angeles [BUI LDING a LJOHN A. LAMBIE. COUNTY ENGINEERRESS ? / �ileU`CASSATT D. GRIFFIN. SUPT OF BUILDING ALITY a ✓
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FOR APPLICANT TO FILL IN CROSS Si.
LEGAL '• J /
DESCRIPTION LOT NO. OWNER
/�) -
MAIL /
BLOCK ' TRACT � /Y1 �® ADDRESS
'— NO. OF SLOGS.
SIZE OF LOT / NOW ON LOT CITY Y TEL
USE OF .." ._ . . -
✓ ., DISTRICT NO. GRO MAP
BUILDINGS '
BK PG
CONTRACTOR
ADOftE55 ,% CONNECTION DATA
i a-l STATION DEPTH
CI TEL.
_ MANHOLE REFERENCE / PPER
4-eo 3 L��- ❑ STATE /�( - -
REGISTRATION N0. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH IRO M
HOUSE SEWER CONNECTING TO 1 y" CURB P.L. M.L.TO P.L. �C>�
PUBLIC SEWER _ @ $3.50 "
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP. N0. JOB N0� '
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $ 2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $ I.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENC TENT
WORK TO HOUSE SEWER Q S 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER.OWDISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
CNARGES'
CONNECTION CHARGE FEE _
OWNER"S PERMIT y 1 Oo '
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 45 i?
I HJ TH18/DATE A'CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACCTT R fl ON ECT T E OVE DESCRIBED BEO EXISTING DW FEEING
TO THE ECIC aEY�'E F1751=
� =NEW HOUSE SEWER
SIGNED IS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR BUILDINGOR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL(:1DRYWELL ElAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 1 ALTER, REPAIR,'SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONN HD PLUGAUSE D
CALIFORNIA OR THAT 1 AAI THE LEGAL OWNER OF T E ABOV
ER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE -7 SEEP.PIT(31 12CESSPOOLS.❑
OF PERMITTEE / P
JOHN A. LAMBIE, COUNTY EN NEER - LIGATION ROBERT.A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. O. GSH "
i.ACO 5 2 3 4 DEC 2 0 4 /4�.5 0 0.