HomeMy Public PortalAbout5032 FARAGO AVE_Sewer__ 76A 64,5:- CE808 - 9/73
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL '
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS ��rr
LOCALITY V�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO Z OWNER
MAIL
BLOCK TRACTi 149r? ADDRESS U
NO OF BLD(.S
SIZE OF LOT �s NOW ON LOT CITY 1/e, (, L NO �
USE OF
BUILDINGS b'L!g DISTRICT NO GROUP MAP PROCESSED BY
SK P^
CONTRACTOR wee �� - r•/ I
ADDRESS0 �� CONNECTION DATA
�'' STATION DEPTH
CITY TEL NO (/
STATE J LIC
LICENSE NO /ib GLASS MANHOLE REFERENCE UPPER
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L
PUBLIC SEWER 0 $7 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 51000
CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W�Ir[[ [I(S[M[MT RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® S300 J.3 ✓ 1 O
OVERFLOW SEEPAGE PIT DRAINFIELD U
EXTN CESSPOOL DRYWELL $300
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING �.
SEWER f300 STATE ENCROACHMENT
MANHOLE $7 00 PERMIT NO IU
INDUSTRIAL N
��
��+ WASTE APPROVAL
OWNER S PERMIT 4 3 00 CHARGES -
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I Q
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON t REIMBURSEMENT FEE
TRACTOR TO COV NECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK BE
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC6RNIA OR THAT THE LE AL OW ER F AN INTEND TO
RESIDE IN THE A13 ESC RE IDE�NT AL PR E I DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ -�
`n *� SEEP PIT(S) El CESSPOOLS ❑
�A/nL'iJJATjON CK M O CASH
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