HomeMy Public PortalAbout5203 DEGAS AVE_Sewer__ C5808 3-6476A64D APPLICATION FOR PERMIT �il
05808 u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDHESS '
WILLIAM A. JENSEN, Sup't of Building 11
OCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
// MAIL r_
BLOCK TRACT O �(l> AOORE95
NO. OF BLDOS. [
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. OUP GRMAP CE59ED BY
BUILOING9
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY L. NO. STATION / DEPTH
41
TE MANHOLE REFERENCE l�R�
REGISTRATION NO. � COUNTY 3 � LOWER
NO. 1 DESCRIPTION WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L. 'CJ
,PUBLIC SEWER ® $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. CL
PITS AND/OR GRAINFIELD ® SIO.00 CO.IMP. NO. JOB NO. U O_
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (J
CONNECT ADDITIONAL
BLDG.
53.00
CONNECT HOUSE SEW BLDG.OR AFFIDAVIT xe1VG ut[R[M RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER ® $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD F
E%TN.,CESSPOOL,DRYWELL,MANHOLE® $5.00 U
ALTER, REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING S
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCROACHMENT 0
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT FEE S z o0
/ CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DE CRIBED E%ISTING DWELLING
TO THE PUBLIC 5E APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1
OWNER OR NEW HOUSE SEWER
ADORES$OW NERB AGENT CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK.SEEP,PIT IS
HEREBY THAT
THE ABO THAT 1 HAVE READ THIS APPLICATION qN0/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREECOMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY 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
RESIDE IN. THE ABOVE EO RE5 I PROPERTY. ABANDON HOUSE SEWER
91GNgTURE BACKFILL SEPTIC TANKS ElOF PERMITTEE '_ SEEP,PIT(S) El CESSPOOLS ❑
DVALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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