HomeMy Public PortalAbout4846 DOREEN AVE_Sewer__ 765065-65
76A642D APPLICATION FOR PERMIT -
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISItN3UILE (A+�/I
JOHN A. LANIBIE, County EngineerAEDREBE O bb I'
COLEMAN W. JENKINS,SGp'I. of Buildq
LOCALiTV �C C a
,. NEARESTFOR APPLICANT TO FML `ROSS ST➢ESCRIPTION LOT NO. OWNER
MAILBLOCK TRACT y�SADDRESSNO. OFSLOGSS12E OF LOT NOW ON LOTCITY TEL. NO.
USE OFBUIDISTRICT HD. GRP MAP PROCESS BY
USE or
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CONTRACTOR n L,AI_
ADDRESS'94.6 7 /sJ � L /`�- �— CONNNECTION DATA _!•_
CITY TEL. 14.1#7e - S STATION K DEPTH
LICNO. LICENSE
NO. �. CLA 55 C y � MANHOLE REFERENCE
OWER
NO. DESCRIPTION OF WORK FEE TYPE OF ON LENGTH L
/151
PUBSEE SSEE EERCONNE CT IND TO $ 5 00� Y. CURB P.L. LEN" .L.
E TIC TAMC, SEEN R P. BNO.
IS
AND/OR GRAINFIELD C SI OA0 CO,IMP. NO. JOB NO, d
HR VA' SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, /� O
PRIVATE DISPOSAL SYSTEM C $ 3.00 .,J
CONNECT ADDITIONAL BLDG, OR AFFIDAVIT AIY SEM[ PECORD.INSTR,NO. DATE
WORT( TO HOUSE SEWER S 3.00 O
OR ABAN DN HOUSE
SEWER OR OIS POSAL SYSTEM C-' $ 3.00
HWY.OR ST.WIDENING
a
E%TN.,CE55 POO L, MANPCLE F S 5.00 y)
STY TEENCROACHMENT
PERCOLATION TEST E $ $.ODI PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT a z 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �'
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES IBED E TING DWELLING
TO THE PUBLIC SE E V
APPROALS DATE INSPECT 'SSIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
HEREBY ACKNOWLEDGE THAT 1 AVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(51
gND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CfjRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES D STATE LAWS REGULATING
PLUMBING AND SEWERS_ CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGEDISPOSAL SYSTEM
CALIFORNIA OR THAT I AM TNF LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RE5IDE IN. THE P OV DESCRIBED RE ID TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS G�
SEEP.PIT(S) LlCE55 DOLS
VALIDATION
CK.
M.O. CASH
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