HomeMy Public PortalAbout5027 FARAGO AVE_Sewer__ 5 J
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TEMPLE C9TV
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CEWS HHH APPLICATION OR PERMIT9
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
' BUILDING AND SAFETY DIVISION ADDRE SG D Y
OFIN A LAMBIE County En ear
C Ali' D GRIFFIN Sup t of Suildmo LOCALITY ri
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL 101,
DESCRIPTION LOT NO 13 OWNER
BLOCK TRACT MAIL
ADDRESS
/� NO OFBLOGS
SIZE OF LOT V "'0
OW ON LOT CITY TEL NO
USE OF
USEBUILDINGS DISTRICT NOGROU 111111MAP PROCESS BY
BK PG
CONTRACTOR �r � a�
ADDRESS T CONNECTION DATA
CITY TEL NO ��� STATION DEPTH
�J p� STATE MANHOLE REFERENC!(:;� ft
REGISTRATION NO �7 v B COUNTY &� LOWER
No I DESCRIPTrON OF WORK EE
HOUSE SEWER CONNECTING TO C
PUBLIC SEWER Co) $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 _
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
SEWER OR IRR ABANDON DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PEST $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE s 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 �b /
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ler—
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY CESSPOOL ❑ DRY-WELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH AM THE LEGAL OWNER F THE ABOVE
DESCRIBED RESIDE IA PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP PIT(S) ❑ CESSPOOLS ❑
OF PERMITTErl�t7 �/,ff
OF VALIDATION ROBERT A WOOD
CIC. M G OpgH SUPERVISING MECHANICAL ENGINEER
A
LFI,o o 6 2 0 'Pdi 3 5 0' G
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