HomeMy Public PortalAbout4525 ELLIS LN_Sewer__ 6A64 ,20 0-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
SEWER-SEWAGE DPO �.
DEPARTMENT OF COUNTY ENGINEER
T
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS Ill
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
-.. ...:...,. ,... -......,.. NEAREST
FOR APPLICANT TO FILL IN CROSS BT.
LEGAL
DESC RIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
OF BLDGS.
SIZE OF LO / OW ON LOT CITY TEL. NO.
DIST,
USE OF
RICT NO. GROUP MAP PROCESSED BY
BUILDINGS �p r�[� BK PG
CONTRACTOR CV V
f' ADDRESS CONNECTION DATA
CITY TEL. N STATION DEPTH
ST MANHOLE REFERENCE LLPAS
REGISTRATION NO. COUNTY — LOWER
NO. DESCRIPTION OF WOR FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.OB
PITS AND/OR DRAINFIELD @ SIO.00 CO.IMP. NO. JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PER IJ.0. w
PRIVATE^DISPOSAL SYSTEM @ $3.00 ,/'•
® CONNECT ADDITIONAL BLDG.OR AFFIDAVIT V/gIVEN EASEMENT RECORDy,INSTR..NO. DATE V
WORK TO HOUSE SEWER @ $3.00 ���/ U
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN_CESSPOOL,DRYWELL,MANHOLE @ $5.00 N
ALTER,REPAIR OR ABANDON HOUSE HW OR ST.W D NI
G �O� Z
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACH ENT/
PERMIT NO.
INDUSTRIALS
WASTEAeFrPROVAL
CHARGES
OWNER'S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE /Gti CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THISDAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CdF ONNECT ADDITIONAL j' ✓ry
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 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 I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESC B RESIDEN L PROP E Y. -
ABANDON HOUSE SEWER -
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE E]SEEP.PIT(S)
❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK. ,
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