HomeMy Public PortalAbout8812 - 8814 ELM AVE_Sewer__ 24650 INSERTS
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COUNTY OF LOS ANGELES- SEWER—SgWAGE .®I,SP®.AL;.
DEPARTMENT OF COUNTY ENGINEER x
BUILDING AND SAFETY DIVISION 'ADDRESSG
Wiineer
LOLIAM AIENSENCSupt ofnBuild ng LOCALITY
= 2s
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 'F OWNER
DESCRIPTION LOT N0. -
Al L
BLOCK, TRACT 'ADDRESS
NLTOF BLOGS. T
SIZE OF LOT�.�� NOW ON LOT" 'CITY G TE NO.
USE OF - DI'STRICT
BUILDINGS N0. GROUP • -.BK MAP P ESSED BY +
- ,
CONTRACTOR ••
ADDRESS 'CONNECTION DATA
� CITY L.NO. STATION DEPTH • • -
-�,.. ❑ STATE ? MANHOLEREFER,ENC UPPER.
REGISTRATION.=NO. - ❑ COUNTY / LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO - -
PUBLIC,SEWER @ $3.00 C :.
TYPE OF/',Cp N IONENGTH FROM
-SEPTIC TANK,SEEPAGE PIT OR Y. //L'`l(1�RB P.L. .L.TO,P.L.
PITS AND/OR DRAINFIELD @ $3.00
' OVERFLOW SEEPAGE PIT,DRAINFIELD - Q
EXTN..CESSPOOL. DRYW.ELL @ $2.00
HOUSE SEWER CONNECTING TO is f ed 0. .
PRIVATE DISPOSAL SYSTEM - @ $1.00 . CO.- 0. - OB NO. -
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. P.
F WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACH V T _
SEWER OR DISPOSAL.SYSTEM @ $1.00PERMIT N0. - 04
O
INDUSTRIAZE"
' 'WASTE APPROVAL
CHARGES.
OWNER'S PERMIT $ 2 QQ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT'FEE
' I HAVE AT THIS*DATE A CONTRACT WITH THE HEREIN NAMED CON- _ _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # APPROVALS �'DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF t9_ NEW HOUSE SEWER A'
OWNER OR a CONNECT ADDITIONAL
OWNERS'AGENT BUILDING OR WORK-
'. ADDRESS < SEPTIC TANK,SEEP.PIT(S) /
_ AND/OR DRAINFIELD
1. HEREBY ACKNOWLEDGE THAT I HAVE.READ-THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY °• CESSPOOL ❑ DRYWELL ❑ J - �_ - i
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR... -
PLUMBING AND.SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED. AS REQUIRED BY LOS ANGELES COUNTY AND.STATE ,OF. 6 DISCONNECT
ABANDON CT PLHOUSEUG
-
CALIFORNIA OR THAT 1 A THE LEGAL OWNER OF THE. ABOVE
DESCRIBED RESIDENTIAL PR ERTY. BACKFILL SEPTIC TANKS ❑ - -
SIGNATURE SEEP.PIT(S)_.❑ CESSPOOLS ❑.
OF PERMITTE �- -
®r VALIDATION ROBERT A. WOOD.
OK. M.0. CASK SUPERVISING MECHANICAL,ENGINEER
Uluo1 5 3-4 fit �j 2 n 3.00
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