HomeMy Public PortalAbout5224 DOREEN AVE_Sewer__ CEBOB
T EBO. 0 APPLICATION OR PERMIT
3
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
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DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BD aDINc // �1
JOHN A. LAMBIE. County Engineer ADDRESS
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL
IINN CROSS ST.
LEGAL _� OWNER
DESCflIPTION LOT NOS X%L�✓ QNIiR_ _A Kim\__
MAIL
BLOCK TRACT _I . & ADDRESS
NO, OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
U5F OF _
BUILDINGS �j(�[/ 015TRICT NO. GROUP MAP PROCESSED'SY
BK PG�I
CONTRACTOR y�,L, ,� v L
ADDRESS '7 "' CONNECTION DATA
CITY TEL. NO.h1 U r STATION �1 .'� j / DEPTH
❑ STATE MANHOLES REFERENCE
REGISTRATION NO. ❑ COUNTY t - `LOWER
NO. DESCRIPTION OF WORK FEE YPE OF CONNECTION LENGTH FROM '
HOUSE'.SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER 55.00P.C.NO.
O
SEPTIC TA K.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD' ® SIO.00 CO.H.P. NO. JOB NO. V
HOUSE SEWER CONNECTING TO I I TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM 53.00
CONN ECT ADDITIONAL BLDG.OR gFFIDw VIT 11v SE.IENi RECO RD.INSTR.NO. GATE
WORK TO HOUSE SEWER @ 53.00
OVERFLOW SEEPAGE PIT,GRAINFIELDA ..I_E
E%TER.ESSPOO N ABANDON HOUSE � 55.00 f/I
ALTER.ORREPAIRDIS OR ABANDON HOUSE ' I STAT QRST.WIDENING
SEWER OR DISPOSAL SYSTEM � 83.00 III STATE ENCROACHMENT
PERMIT NO.
- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s i o0
CONNECTIONCHwRGE FEE CHARGES
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TO THERPUBLICCONNECT SEWER THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
GATE INSPECTOR''6 51G ATURE
SIGNED THIS DAY OF 19_
OWNER ORM AA
I ..NEW HOUSE SEWER 1�
OWNERS AGENT_` �(L(/V CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.PIT(5)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE ICORRECT ANO 'GREE COMPLY
WITH ALL COUNTY ORDINANCES
S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. _. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE'LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THEABO E SCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE - B FILL SEPTIC TANKS ❑
OF PERMITTEE
_ - SEEP.PITI51 ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
(p5 6 0 4"� OCT16 1 0 D 7.0 0 011
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