HomeMy Public PortalAbout5116 FARAGO AVE_Sewer__ TEMPLE GETV
c808 D APPLICATION FOR PERMIT
canoe a-sa COUNTY OF LOS ANGELES
SEWER-SE GE ®ISPOSA4.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDrnG -
ADDRESS ' - -
IOHN A. LAMBIE, County Engineer 61
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cRoss sr.
LEGAL
DESCRIPTION LOT N0. OWNER
BLOCK TRACT .13 MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUPK MAPPG ROCES BY
CONTRACTOR
ADDRESS CONNECTION DATA
CITY ` TEL.N0. 09 /n i! STATION DEPTH
/ � U STATE MANHOLE REFERENCE r
REGISTRATION NO. ❑ COUNTY PLOWER
NO. DESCRIP ION OF WORK- FEE u
HOUSE SEWER CONNECTING TO qf� a-i
PUBLIC SEWER @ $3.00 C� '`� TYPE OF CONNECTI LENGTH FROM •s'a""
7
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IM NO. C _ JOB N0.
bfff CONNECT ADDITIONAL BLDG.OR TRUNK P IT N0. ROAD P N0.
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHME
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL ^�•��^•,
CHARGES
OWNER'S PERMIT S 2 CO CONNE%jPf CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INFSPECTpR'S S fiNATURE
TO THE PUBLIC SEWER. '
,l
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER ORJ - - CONNECT ADDITIONAL
OWNERS AGENT`' a BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS-REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGEEPAIR,SEWER DISPOSAL EM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE PROPERTY. - BACKFILL SEPTIC TANKS ❑
SIGNATURE
EEP.PIT(S)
E] CESSPOOLS ❑
OF PERMITTEE
®P VALIDATIO ROBERT A. WOOD
CK, M.0. CASH SUPERVISING MECHANICAL ENGINEER
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