HomeMy Public PortalAbout5214 DEGAS AVE_Sewer__ CEBDB 3-E4 86620 APPLICATION FOR PERMIT
CE
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
JOHN A. LAMBIE, County Engineer ADDRESS I
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT �� ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GflOUP MAP qESSEO BY
BUILDINGS .� BK PG
CONTRACTOR ) I z /f �y
ADDRESS ) CONNECTION DATA
STATION �f DEPTH
CITY 1, O. p.C_. H
%ti;-. E
TE MANHOLE REFERENCE LOWER
REGISTRATION NO. Z ' COUNTY
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO -- Y. CURB P,I.R M.L.TO P.L. L
PUBLIC SEWER a $5.00
SEPTIC TA N K.SEEPAGE PIT ON P.C.NO.
CO.IMP. NO. JOB NO. d
PITS AND/ORWEE O GRAINFIELD ® $10.00
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM ® 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVIR I 1ASEK91IT RECORD,INSTR.NO. DATE C
WORK TO HOUSE SEWER ® S3.00 Q
OVERFLOW SEEPAGE PIT.GRAINFIELD h
EXTN..0 ESSPOOL,DRYWELL,MANHOLE® $5.00 U
HWY.OR ST.WIDENING IL
ALTER.REPAIR OR ABANDON HOUSE d
SEWER OR DISPOSAL SYSTEM Q $3.00 STATE ENCROACHMENT y
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
11 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF —19
OWNER OR NEW HOUSE SEWER �Ijl
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SPIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD D
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ OftYW ELL ❑
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 D15POSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AN
p
RESIDE IN. THE ABOVE DESCRIBED RESID T L PROPERTY. ABANDON HOUSESEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT ISI ❑ CESSPOOLS ❑
,,�ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.0. CASH
LAj,o 1 7 0 6 MAY 17 1 0 D 7,00-
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