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Home My Public Portal About5204 FARAGO AVE_Sewer__ 62 76A64262 APPLICATION FOR PERMIT -5 C r 6A842 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER F BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE County Engineer ADDRES WILLIAM A JENSEN Sup t of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT y 7 ADDRESS / NO OF BLOGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF DISTRICT NO GROUP AP OC EJ11 BUILDINGS BK PG CONTRACTOR ADDRESS CONNECTIOf4 DATA CITY TEL NO y O {�r �i _/ATI ON v'7��/� DEPTH ❑ STATE MANHOLE REFERENCE (UPPER REGISTRATION NO ❑ COUNTY l NO DESCRIPTIO OF WORK FEe TYPE OF CONNECT LENGTH FROM HOUSE SEWER CONNECTING TO f Y P)L M L TO P L Vl J PUBLIC SEWER @ $5 00 ((( SEPTIC TANK SEEPAGE PIT OR PC NO PITS AND/OR DRAINFIELD Q $1000 CO IMP NO JOB NO V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM @ $3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO .,(TE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN C ESSPOOL DRYWELL MANHOLE @ $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT PERMIT NO e7 i INDUSTRIAL WASTE APPROVAL OWNER S PERMIT $ 2 Oo CHARGES AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED 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 OR NEW HOUSE SEWER OWNERS AGENT ( f CONNECT ADDITIONAL v I ADDRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ IHEREBY 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 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABO V D CRIBED RESIDENTIAL P OPER T ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMrrTEE SEEP PIT(5) ❑ CESSPOOLS ❑ VALIDATIONS ROBERT A WOOD CK M O y(CASH ; SUPERVISING MECHANICAL ENGINEER LA0 2 7 2 8-2 APR 1 1 () D 7,C,0, s' A�7d,4"t 768043 62 76A642D APPLICATION FOR PERMIT -� COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE County En eer ADDRE WILLIAM A JENSEN Sup t of Building LOCALITY CE— NEAREST FOR APPLICANT TO FILL IN `ROSS ST LEGAL / q _ G DESCRIPTION LOT NO r r� OWNER !w MAIL BLOCK TRACT ADDRESS / NO OF BLDG5 SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY y/ K owt ey—� �P/G CONTRACTOR / _/. ADDRESS T nONNECTION DATA CITY TEL NO L/ GlL��l Q ST-Al,ON T IONyyyDEPTH El STATE MANHOLE REFERENCE/ PPER REGISTRATION NO i,� P ❑ COUNTY NO DESCRIPTION OF WORK- FEE TYPE OF CONN TI LENGTH FROM ¢ HOUSE SEWER CONNECTING TO Y CU P L M L TO P L PUBLIC SEWER @ $5 00 O SEPTIC TANK SEEPAGE PIT OR J C NO PITS AND/OR DRAINFIELD Cm $10 00 CO IMP NO JOB NO V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM Q $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DAYE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOLDRYWELL MA HOLE @ $500 ALTER REPAIR OR ABANDONOUSE HWY OR ST WIDENING SEWER OR DISP L SY E @ S300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWCHARGES NERS PERMIT $ CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TOCOVNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ; APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OF 19_ 3-&& OWNER OR NEW HOUSE 5G,IELER K-z-G3 OWNERS AGENT—��/ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ IHEREBY 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 ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PER MiTTEE SEEP PIT(S) El CESSPOOLS ❑ VALIDATION ROBERT A WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH LAAO 2 7 29-6 APR 1 D 2 J.0 0 J '