HomeMy Public PortalAbout5219 DEGAS AVE_Sewer__ CDB 3EB -Eq
76A642D APPLICATION FOR PERMIT �I
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
JOHN A. LAMBIE, County Engineer 11 ADDRESS /
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEApE6T
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL
DE Be RIPTION LOT NO, OWNER J�
Q
MAIL D, /
BLOCK TRACT ADOR
MAILESS r�I
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PPOCESSED BY
BUILDINGS
BK PG
CONTRACTOR
ADDRESS A �J CONNECTION DATA
BTATI ON DEPTH
CITY EL. NO. Ao X 9 /
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REGISTRATION NO. �Z9TOTEUNTY MANHOLE REFERENCE
{�3 ❑ ��F LOWEq
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM c+J
HOUSE SEWER CONNECTING TO Y. CURB .L M.L.TO P.L. O(
PUBLIC SEWER a 33.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. �.
PITS AND/OR GRAINFIELD ® SI0.00
CO.IMP, NO. JOB NO. 0 p.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wM{[[ {1{[x[xi RECORD.INSTR.NO. DATE �.
WORK TO HOUSE SEWER ® $3.00 O
OVERFLOW SEEPAGE PIT.DRAINFIELO V
E%TN.,CESSPOOL.ORYWELL.MANH O LE 111 33.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING U.1
SEWER OR DISPOSAL SYSTEM ® 33.00 (A
STATE ENCROACHMENT
PERMIT NO, Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE J CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E}ISTING DWELLING
TO THE PUBLIC SEWE �1 .. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF Q,B 19Ids
OWNER OR L NEW HOUSE SEWER p
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTICI HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLICATION A../. GRAIANK.NFIELD SEEP.PITI6)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
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 ON
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE CRIBEO pE6 L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE 4HL BACKFILL SEPTIC TANKS
E ❑
OF PERMITTEE SEEP.PIT(S) O CESSPOOLS ❑
VALIDATION ROBERT WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
LACO 1 7 0 OG PAY 17 1 0 D 7.00-
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