HomeMy Public PortalAbout5206 FARAGO AVE_Sewer__ 6A642D 10-63
76A64APPLICATION FOR P�ERM1 �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
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JOHN A LAMBIE County Engineer p��WILLIAM A JENSEN Sup t of Building ��'Y ���TFOR APPLICANT TO LIN 7 ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF 13LOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NOGRO MAP PROCESSED BY
BUILDINGS
PG
CONTRALTO L� �/ r2rqk"?
ADDRESS CONNEC ON ATA
CITY NO - Q STATION DEPTH
STATE UPPER
a7 MANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION F WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L }
PUBLIC SEWER @ 55 00 P C NO d
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO O
PITS ANDOR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 53 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300 G
OVERFLOW SEEPAGE PIT DRAINFIELD l!J
EXTN CESSPOOL DRYWELL MANHOLE @ 55 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER$ PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE /�}� CONNECTION CH RGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO 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 CONNECT
BUILDING OR WORKAL IE��/�
ADDRESS b
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 ❑
I 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 ABOVE DE RIBED RESIDENTI L PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP PIT(S) ❑ CESSPOOLS
or
VALIDATION ROBERT A WOOD
G
M o CASHSUPERVISING MECHANICAL ENGINEER
M 0 CASH
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