HomeMy Public PortalAbout5034 DOREEN AVE_Sewer__ ..E.6G420 O LSS APPLICATION FOR PERMIT
SS
DIVISION OF BUILDING AND SAFETY -SEWER—SEWAGE DISPOSAL
Deportmentrof County Engineer . 11 =
County of Los Angeles BUILDING —G
'JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GR I FFIN.-SUP'TOFEIUILDIN. LOCALITY ,_411 1
FOR APPLICANT TO FILL' IN
NEAREST
ROSS ST.
LEGAL` OWNER -
DESCRIPTION LOT N0. / /}
ADDRESS
O
.SIZE OF LOT UQ '(,LV'-JNOW ON LOTS CITY L. NO.
USE OF
BUILDINGS DISTRICT NO. OUR MAP
W
BK PG
CONTRACTOR a� ✓!� _
CONN CTION DATA
ADDRESS, - -
STATION _ - DEPTH _
CITY TEL. NO.
' MANHOLE.RE ERENCE .. UPPER
❑ STATE' - LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION'OF WORK FEE CVsre/' -
HOUSE SEWER CONNECTING TO TYPE OF CONN CTION " LIB1GTH FROM
Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $`3:50 J ,
SEPTIC TANK:.SEEPAGE.PIT OR
PITS AND/OR DRAINFIELD' @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD - P. C. NO. -
.EXTN.,CESSPOOL,DRYWELL`,M AN HOLE $2.00 CO. IMP. NO. JOB NO.
HOUSESEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 'TRUNK PERMIT NO 'R D PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCEO MENT
WORK TO HOUSE SEWER' @ $1:00 PERMIT O -
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL-SYSTEM @ $100 WASTE APPROVAL
CHARGES .
CONNECTION CHARGEII'd
OWNER'S PERMIT S t oo
AUTHORIZATION TOTAL £EE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITHTHE HEREIN NAMED CON- APPROVALS - _ DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED'EXISTING DWEULING
TO.THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL T /
OWNER .OR .. - BUILDING OR WORK .;
OWNERS AGENT SEPTIC TANK,SEEP, NT(S) '✓
ADDRESS - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT.THE,ABOVE 15„CORRECT-.AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE .LAWS REGULATING 'ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY-CERTIFY THAT' I AM PROPERLY REGISTERED ANO/OR AND
DISCONNECT PLUG
LICENSED AS REOUI ED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE D '
CALIFORNIA OR T T 1 AM HE LEGAL WNER OF THE =ABOVE _
DESCRIBED RESID IAL PRO TY. BACKFILL SEPTIC TANKS C' _
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS D.OF PERMITTEE
, I
JOHN A..LA . COUNTY EN NEER VALIDATION ROBERT A.WOOD. CHIEF PLEIG. INSPECTOR
CK. N. -
I
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