HomeMy Public PortalAbout5301 DEGAS AVE_Sewer__ 75A642 "51 APPLICATION FOR �RMIT
CE 083
COUNTY OF LOS ANGELES SE1R/ER-SEUVAGE DISPOS�4L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS q
IONN A, LAMBIE. Courtly Engineer ADDRESS
WILLIAM A. IENSEN, Sop'1 of Building_ LOCALITY
NEAREST
FOR APPLICANT TO FILL. IN CHO" sr.
LEGAL �` OWNER I C� /W/f
DESCRIPTION LOT X0.
BLOCK TRACTr/J MAIL _
�) �G ADDRESS t� 'r
NO.OF BUGS.
SIZE OF LOT NOW ON LOT CITY -7;;-V'allir TEL N0. T
USE OF
BUILDINGS DISTRICT NO.I GROUP MAP PROCESSED BY
CONTRACTOR BK P6
G41 7 Jr • V L1—�/�/
ADDRESS ,,, 2� CONNECTION DATA
CITY .P N ' / ^J TEL.NO. �/-LC` STATION DEPTH
/ / J
REGISTRATION NO. (' 1 -7 - H COUNTY MANHOLE REFERENCE MP
NO. DESCRIPTION OF FEE o-
CIA
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK.SEEPAG E PI TOR T. CURB P.L. M.L.TO P.L. �J
PITS AND/OR DRAT N FIELD @ 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD }a
EXTN..CESSPOOL. DRYWELL @ 52.00
HOUSE SEWER CONNECTING TO P.C.N0, �� O
PRIVATE DI SPOSAL SYSTEM @ $1.00 CO,IMP. N0. -_�pR-H8: �� � U
WORK TO HOUSE SEWER BLDG.OR @ $I 00 TRUNK PERMIT N0. ROAD PERMIT NO. w
SEWER OR DAIR SPOSAL SYSTE INA MOUSE Qy SI.00 STATE ENCROACHMENT Q
PERMIT N0,
INDUSTRIAL
WASTE APPROVAL
nrc CHARGES Z
O�[Yyy EWS FERMIS S C2 OD CONNECTION CHARGE FEE
AUTHORIZATION J
TOTAL FEE C REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING APPROVALS DATE, INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �)) h //
SIGNED THISDAY OF 9S� NEW xousE SEWER
OWNER / CONNECT ADDITIONAL
OWNERS AGENT rte' BUILDING OR WORK
ADDRESS- SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 4 HAVE READ THIS APPLICATION
AND STATE THAT THEABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEGAL OWNER/0F THE ABOVE
BACKFILL SEPTIC TANKS ❑
SIGNATURE
DESCRIBED RESIDENTIA PR ERTp'. _ /I /� SEEP,PIT(5 ❑ CESSPOOLS
al
OF PERMITTE /X//( !/i ALJ
AJIDATION ROBERT A. WOOD
DIL M.o. WH SUPERVISING MECHANICAL ENGINEER
..r
LL 1 6 9 At 71 ] 1 0 D 5.00