HomeMy Public PortalAbout10765 FAIRVIEW AVE_Sewer__ ` f
7BA642U APPL ICATt®1�1'
CE808 8 59� 7
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Fairview
ADDRESS
JOHN A LAMBIE, Count Engineer
CASSATT D GRIFFIN, Sup't o4 Building LOCALITY e
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NOOWNER G Qr 1Qc
BLOCK _ TRACT �"CI� ADAESS 21035 Mesa Rica Road
NO OF BLDGS ovina
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OFRes
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
pp
CONTRACTOR • • • Constr. O• �/ � BK PG ' e
ADDRESS 1)6 • Bleecker a CON ECTION i5ATA
'6'1dW:tn Pat ED 8 392h CITY TEL NO STATION � DEPTH —
REGISTRATION NO ❑ STATE MANHOLE REFERENCE UPPER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L C
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C OD
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT
WORK TO HOUSE SEWER @ $1 00
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION HARGE FEE
AUTHORIZATION TOTAL FEE 07D 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 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL ✓
OWNERS AGENT— BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT f PRO ERLY REGISTE D AND/OR DISCONNECT PLUG AND '
LICENSED AS REOUI, Y S NG ES C NTY _1 STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR _ER 0 THE ABOVE
ER
DESCRIBED REST R BACKFILL SEPTIC TANKS ❑
SIGNATURE A_ SEEP PI (S) ❑ CESSPOOLS El
OF PERMITTEE1 (E3�
VALIDATION ROBERT A WOOD
Ck y M o CASH SUPERVISING MECHANICAL, ENGINEER '
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