HomeMy Public PortalAbout5202 DEGAS AVE_Sewer__ -E9
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL IILIII
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAADDHESS
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JILDIOHN A. L AND
S County ETT Engineer L �[`J
WILLIAM A. JENSEN. Supt of Building - �•
gLiTYRESTFOR APPLICANT TO FILL IN BS ST.
LEGAL
_DE SC
RIPTI ON LOT NO. OWNER a
MAIL
BLOCK TRACT E ADDRESS
NO. OF eLDGs. J
S1ZE OF LOT NOW ON LOT / CITY TEL. NO.
USE OF DISTRICT NO. GROUP MqP P CEEBEO BY
BUILDINGS
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CONTRACTOR ✓/�� r t
ADDRESS CONNECTION DATA
CITY _ NO. Y STATION DEPTH
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STATE MANHOLE REFE PENCE
REGISTRATION NO. /y�� COUNTY 7 LOWEfl
NO. DESCRIPTIO OF WORK FEE TYPE OF CONNECTION LENGTH FROM YV
OUSE SEWER CONNECTING TO Y. CUgB P. M.L.TO P.L.
PU SL SEWER E3.00
SHEPTIC TANK.SEEPAGE PIT OR P.C.NO. }
PITS ANO/OR DRAINFIELD E10.00 CO.IM P.NO. JOB NO. 7d 0
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 1 V
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT HSESEWS
EADDITIONAL BLDG.OR AFFIDAVIT [Iv As[M[rvi RECORD.INSTR.NO. GATE C
WORK OVERFLOW
HOUSE SEW IT ® E3.00 Q
OVERFLOW EEOL,DR WELL, AINFIELD.OI_E U
EXT ER.ESSPOOOR ABANDON HOUSE � E5.00 U
ALTER,REPAIR OR ABANDON MOUSE HWY.OR ET.WIDENING d
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMITs z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEW DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF )12A I
1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
`/— CONNECT ADDITIONAL
ADDRESS h�A�( J�- BUILDING OR WORN r
SEPTIC TANK,SEEP.FIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH 15 APPLICATION AND/OR ORAINFIELO
ANO STATE THAT THE A30VE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIOE IN, THE ABO ,3CRIBEO RES L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE Z SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M.O. CASH
LACo l 7 0 a'�- MAY 17 1 0 D 7.0 0