HomeMy Public PortalAbout5102 DOREEN AVE_Sewer__ CEeDB 2D70 - APPLICATI N FOR P
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONeUILUInc ,/
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS �/ /,�72_ 7J.
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY 77
FOR APPLICANT TO FILL IN -' CROSSNEAREST
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(PRINT OR TYPE ONLY) ST.
61
LEGAL
DESCRIPTION LOT NO, OWNER `
MAIL �_ /
BLOCK TRACT ^ // O AOON S54
NO. OF BLOCS. yy
SI2E OF LOT , NOW ON LOT / CITY TEL. NO, v-7 G�
USE OF
BVILDINGS DISTRICT NO. GROUP CL155 MAP PROCESSED BY
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CONTRACTOR-
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ADDRESS' yn CONNECTION DATA
CITY �! yG Z` Z�/� STATION / A S DEPTH
STATE LI
LICENSE NO. C ✓
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NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO '(/ /}�j"J T. CURB P.L. M.L.TO P.L. -PUBLIC SEWER ® 3500 (f(/
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIE40 ® 310.00 CO.IMP.NO. // JOB NO,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, f/V'/ .f3 O
PRIVATE DISPOSAL SYSTEM ® 33.00
CONN E CT ADDITIONAL BLDG,OR AFFIDAVIT AIY xz[x[x RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ® 33.00 {,J
OVERFLOW SEEPAGE PIT.ORAINFIELO
EST N..CESSPOOL.DRYWELL.MAN H OLEO SS GO
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM ® 33.00 STATE ENCROACHMENT U
PERMIT NO. W
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STRIAE
WASTE
WASTE APPROVAL
OWNERS PERMIT s - 00 CHARGES
AUTHORIZATION I TOTAL FEE t9
-v CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING OW ELLING
TO THE PUBLIC SEWER. APPROVALS DATE (NSP CTOR's SIGNATURE
SIGNED THIS DAY OF 19_ L_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PITI51
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. / CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY A AM ROPERLT RE 15TERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUI D Y LOS AN LES COU Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T THE LE OW E R.
AND INTEND TO
RESIDE IN, THE O A ESC BE REST N PROPERTY. OISCONry ECT PLUG ANp
ABANDON HOVSE SEWER
SIGNATURE TURE E BACKFILL SEPTIC TANKS ❑
SEEP.PIT ISI ❑ CESSPOOLS ❑
VALEDATIO JACK R. ALLEN
CK. M.0. CASH SNPERVISING MECHANICAL ENGINEER
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