HomeMy Public PortalAbout4912 DOREEN AVE_Sewer__ 9 - APPLICATION FOR PERMIT 1
e&E66DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL +
Department of County Engineer
^p County of Los Angeles BUILDING /�
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 9/Z �. UE.
® CASSATT-0. GRIFFIN. SUPT OF BUILDING LOCALITY �V Am T
FOR APPLICANT TO ILL IN NEAREST
CROSS ST.'.J �'P�✓ YY-•�_
DESCRIPTION LOT NO./w� OAT.�'Gi� OWNER
BLOCK TRACT --lF- LL MAIL
'.3 � Q� ADDRESS
I� ♦ NO. OF BLDGS. / CITY TEL. NO.
SIZE OF LOT r p fy V NOW ON LOT -
USE OF /// / P.-�_ ` �—
BUILDINGS CN-Ad O� DISTft ICT NO., GROUP MAP
BK PG
. CONTRACTOR C� a w
/ CONNECTION DATA
ADDRESS-'��Z� an d Q J�
CITY s , TEL NO. STATION �7 DEPTH 46 '
0 MANHOLE REFERENCE r UPPER
REGISTRATION NO. r-, 9'I C A LO COUNTY J
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF TION - LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB Aq- M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD (_A $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. O.
EXTN.,CESSPOOL,DRYWELL.MAN HO LE Q $2.00 CO. IMP. NO.HOUSE SEER
JOB N0. /'�
PRIVATE DISPOSAL SYSTEMG TO 0 $1.00 TRUNK PERMIT NO. ROAD PERMIT NO,3Za Z6
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
Q $1.00
WORK TO HOUSE SEWER PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $I.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE '
OWNER'S PERMIT 5 t 00
' AUTHORIZATION TOTAL PEE �
S REIMBURSEMENT FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER _ In4o A
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR Ao /l.L / BUILDING K,WORK
i OWNERS AGENT C G(/ ..(/ �V SEPTIC TANK.SEEP, PIT(5)
ADDRESSC/��� ' AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT F HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED SAND/OR pISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANO STATE OF ARAN DON HOUSE SEWER
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL ROPERTY. BACKFILL SEPTIC TANKS❑ -f g .!
SIGNATURE ,. /p1 SEEP. 'IT
(SI ❑ CESSPOOLS[A
OF PERMITTEE i V/ �-� 3 ve, "
JOHN A. LAMBIE;COUNTY ENGINEER VA IDATIO ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N.0. CASX
Aco2 5 JAN27 4 - 4.50