HomeMy Public PortalAbout4836 DOREEN AVE_Sewer__ 1O
CROOB1-S] APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES _ _ SEWER=SEWAGE DISPOSAL
DEPARTMENT-OF COUNTY ENGINEER ' -
BUILDING AND SAFETY DIVISION BUILDING -
JOHN A. LAMBIE. County. Engina•r ADDRESS
CABSAT7 D. GRIFFIN, Sup l of Building LOCALITY
F04 APP caoss sir
[REGISTRATION
7 t
TION OWNER ,�I -
TRACT & MAIL
ADDRESS
]. NO.OF BLDGS.
LOT Z 0 NOW ON LOT CITY TEL.N0.
USE
GS DISTRICT NO. GROUP MAP Gfy.�
TO `7PY
CONNECTION DATA 77 [[�1
TEL.NO STATION --j"o L} DEPTHSTATE I
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ATION NO. ® COUNTY MANHOLE REFERENCE ') 2- NA UPPER
NO. DESCRIPTION OF WORK FEE /� O WE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 41 "
SEPTIC TANK.SEEPAGE PIT OR TYPE OF CO TIONP. LENGTH FROM /
Y, B P
PITS AND/OR DRAINFIELD @ $5.00 L. M.L.TO .L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXT N..CESSPOOL.DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. /:3 :2- JOB NO.
CONNECT ADDITIONAL BLOR qq p
WORK TO HOUSE SEWER 0 $1.00 V t TRUNK PERMIT NO. ROAD PERMIT NO. /
ALTER,REPAIR OR ABANDWHOUS5
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
,INDUSTRIAL.
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ -.21
00 F, CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE (n 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH-THE NAMED CN.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIISTIING DWELLING APPROVALS DATE INSPE TOWS SIGN ATURE
TO THE PUBLIC SEWER.
SIGNED THIS—DAY OF 79_ NEW HOUSE SEWER
OWNER OR + - - -CONNECT ADDITIONAL -- - - "
OWNERS AGENT BUILDING OR WORK
ADDRESS "'- - - - -- - - -SEPTIC-TANK,,SEEP,.PJT(S)
AND/OR DRAINFIELD _
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE,ABOVE IS CORRECT AND-AGREE-TO-COMPLY CESSPOOL ❑ DRYWELL❑ - '- -- -WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR, SEWER OR
1 'HEREBY CERTIFY-THAT I AM -PROPERLY REGISTERED
AND/OR -SEWAGE DISPOSAL SYSTEM - - -— - - -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THATJ-AM T LEGAL OWNER OF .TXE ABOVE_ ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPE (/J BACKFILL SEPTIC TANKS ❑�-
SIGNATURE _ /1 JCS - �.( ti/i SEEP. PIT(s) D CESSPOOLS _
OF PERMITTE 4 /t� T'K-�'Y "✓
I
®r VALIDATION ROBERT A. WOOD -- - - -
CK. _
iii.0. _ CASH- SUPERVISING MECHANICAL ENGINEER
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