HomeMy Public PortalAbout4940 DOREEN AVE_Sewer__ E808-D
CAPPLICATION FOR PERMIT' ,
eeoe-a-sa COUNTY,OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING-AND SAFETY DMSION BUILDING, �
JOHN A. LAMSIE, County F ,g�mgineer ADDRESS V� -
40
Pt 5
CASSATT D. GRIFFIN. Su of. fl;;g LOCALITY .La
Bu
., NEAREST
FOR APPLICANT TO FILL. IN CROSS sr.
LEGAL p
DESCRIPTION LOT NO. OWNER C (.
' BLOCK TRACT MAIL u [A
//�� y ADDRESS L-
SIZE OF LO (J/� 13O} NOWONLOTS CITY �• .
7 SIL KrL.Q- TEL. N0.
USE OF- :.
BUILDINGS DISTRO. GROUP BK MAP PG PRO SSED
CONTRACTOR r Q �� �� T - 3
ADDRESSto 3 410f �-�f' / _F CONNECTION DATA
CITTA/a, A(D/,f_ Woo EL. NO. STATION DEPTH
STATE MANHOLE REFERENCE �'j
REGISTRATION NO. COUNTY oG OWER
No. DESCRIPTION OF W RK FEE - -
HOUSE SEWER CONNECTING TO O D
PUBLIC SEWER @ $3.00
f SEPTIC TANK, SEEPAGE PIT OR TYPE OFC ION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 - Y. URB' P.L. M.L.TO P.L.
- OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $2.00 -
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL
-CHARGES
OWNERS PERMIT $ 200' CONNECTION.CHARGE FEE
AUTHORIZATION1 TOTAL FEE OO REIMBURSEMENT FEE
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS - DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
s
SIGNED THIS DAY OF Jg_ NEW HOUSE SEWER -.
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK '
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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 ALTER, REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL OP TYP' BACKFILL SEPTIC TANKS ❑
SIGNATURE j' SEEP. PITS) ❑ CESSPOOLS
OF PERMITTE / -
b-I fi2x jK ,�f1/ (�' O'� 'j�,• ��� .VALIDATIOI�,, ROB MECHA WOOD
.LB. M.o. W SUPERVISING MECHANICAL ENGINEER
LACO4 2 1 9rn OCT'2 1 '0 Jc
A n
. ./ 'r+trl7iLL°err✓ _