HomeMy Public PortalAbout10939 DANBURY ST_Sewer__ pppp BB pp/� pp pp�y r 1��y��pggy�
Yeana'S APPLICPV PON FOR ERMI 1 -
ceeoe a-en COUNTY OF LOS ANGELES
SEV1/ER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY 71
DIVISION ADDRESS
JOHN A. LAMBIE, Couaty. Eng aeer ADDRESS
CASSATT D. GRIFFIN, Supt of Buildiuq LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CR055 BY
LEGAL OWNER
'. DESCRIPTION LOT NO.
BLOCK TRACT MAIL
ADDRESS
N0.OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OFDISTRICT N0. CRO , h ^
BUILD'
J_ I UP MAP PROCESSED BY
NGS
(JY F}AIP BK PG
CONTRACTOR
ADDRESS CONNECTION DATA 1 H�/F�LS%
CITYYTEL.NO. STATION sDEPTH
J qq,(/ / O� TE MANHOLE REFERENCE UPPER
REGISTRATION NO. IZZAIb c.C,. COUNTY lea
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ,s
PUBLIC SEWER @ $3.00 -
TYPE OF CONNECTILENTFROM
SEPTIC TANK,SEEPAGE PIT OR O GH
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB .L. M.l.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @31.00 CO.IMP. NO. JOB NO. _
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $tOO TRUNK PERMIT N0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 OO CONNECTION CHARGE FEE
-• AUTHORIZATION TOTAL FEE J REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS�AAX OF 19 NEW HOUSE SEWER
'- OWNER OR t\ t CONNECT ADDITIONAL
u OWNERS AGENT �l 't 1 A I
ILDING OR WORK
AOOgE55 PTIC TANK,SEEP. PITS)
D/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLSSPOOL ❑ DRTWELL Cl
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. WAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OSCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OANDON HOUSE SEWER
CALIFORNIA OR THAT 1 THE LEGAL OWNER OF THE ABOVDESCRIBED RE TIAL PERTY.� CKFILL SEPTIC TANKS ❑EP. PIT(S) ❑ CESSPOOLS ❑
SIGNATURE 7
OF PERMITT
®. ALIDATION ROBERT A. WOOD
CK. H.o. GSH SUPERVISING MECHANICAL ENGINEER