HomeMy Public PortalAbout8838 ELM AVE_Sewer__ CE808
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76g64 •APPLICATION FOR PERMIT �}
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1 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING -
JOHN A. LAMBIE, County Engineer
ADDRESS - J
1 ---- —._..__ --- --- -_
WILLIAM A. JENSEN, Sup"t of Building
L OCALiTY
NEAREST
FOR APPLICANT TO FILL IN GRD55 5T. —_—
LEGAL
DESCRIPTION LOT NO. OWNER '*
_ -
BLOCK TRACT ADDRESS ,
NO, OF BIL DGS.
SIZE OF LOT NOW ON LOT CITY TEL NO. -
USE OF
DISTRICT NO. GROUP MAP PROCESSED BV
BUILDINGS SK PG
:ONTRACTOR
IDDRESS CONNECTION DATA _
STATION DEPTH
TY TEL. NO.
-- ---_------- STATE - UPPER
Imo{ MANHOLE REFERENCE LOWER r
GISTRATION NO.!" LJ COUNTY a
GESCRIPT�I OF WOKI� FEE TYPE OF CONNECTION LENGTH FROM O
HOUSE 5EWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. (J
PUBLIC SEWER @ $5.00 P.C.NO.
-- W
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. JOB NO. .J
PITS AND/OR DRAINFIELD @ S10.00 U-
SHOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 __ y'
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD;INSTR.NO. DATE Q
WORK TO HOUSE SEWER @ $3.00
t -RFLOW SEEPAGE PIT.DRAINFIELD --
EXTIN CESSPOOL.DRYWELL.MANHOLE @ $5.00 O
ALTER.REPAIR OR ABANDON HOUSE - � HWY.OR ST.WIDENING
SEWER ORDISPOSAL YSTEM @ $3.00 STATE ENCROACHMENT
-_.--- -_-- _S_ WI PERMIT IN
INDUSTRIAL
WASTE APPROVAL
t CHARGES
OWNER'S PERMIT �$ 2'. Oo
--_--� CONNECTION CHARGE FEE
:HORIZATION TOTAL FEE --
REIMBURSEMENT FEE
VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. -
TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
IE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
ED THIS DAY OF 19_
t OR NEW HOUSE SEWER
R5 AGENT CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK.SEEP, PIT(S)
'REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
NLL COUNTY ORDINANCES AND STATE LAWS REGULATING
qG AND SEWERS. CESSPOOL ❑ DRYWELL ❑
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
D AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
NIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
N. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
TE BACKFILL SEPTIC TANKS El
SEEP.PITIS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH