HomeMy Public PortalAbout5026 FARAGO AVE_Sewer__ f
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76A642 6rBUILDING
APPLICATION FOR PERMIT
76A842D I..I
NTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
ENT OF COUNTY ENGINEER
AND SAFETY DIVISION fNEAREST
71- 4
S y�
A LAMBIE County En u eer 06
A JENSEN Supt of Building
7
OR APPLICANT TO FILL IN 55 ST
LEGAL
DESCRIPTION LOT NO113
OWNER
MAIL
BLOCK 06 TRACT ADDRESS
NO OF SLOGS IRA
SIZE OF LOT NOW ON LOT CITY Q1i✓ � TEL NO t/Q
USE OF DISTRICT NO GROUP MAP PROCESS B.K
BUILDINGS 1
ByK J PG
CONTRACTOR O
ADDRESS Pro,
/% CONNECTION DATA
CITY R TEL NO� l!O �GPQ STATION /, DEPTH
70
STATE MANHOLE REFERENCE
REGISTRATION NO 113 v COUNTY /, LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LBrNGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L L�
PUBLIC SEWER @ $5 00 0
PC NO
SEPTIC TANK SEEPAGE PIT OR r ,
CO IMP NO .10B NO
PITS AND/OR DRAINFIELD @ $10 00 V
HOUSE SEWER CONNECTING TO T E MI NO ERMI O
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W VER EasEMENi RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD N
EXTN CESSPOOL DRYWELL MANHOLE @ $500 �{
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING i
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT $ ♦00 CHARGES
AUTHORIZATION I TOTAL FEE �7 CONNECTION CHARGE FEE
IHAVE 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 THIS DAY OF _19-
OWNER
9_OWNER OR /J NEW HOUSE SEWER f Ff
OWNERS AGENT__���—r�/� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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 ABOVX DEALRISED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT fS) ❑ CESSPOOLS ❑
VALIDATI ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
[ ,Q5304� OCT 9 1 0 D � QQ�