HomeMy Public PortalAbout5224 FARAGO AVE_Sewer__ -yG Z�4
76A642 81 APPLICATION FOR PERMIT
78A842D
COUNTY OF LOS ANGELES SEWER-SEWAGE ®VSA ,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 7 AETELNO.
JOHN ALAIABIE County Eng�nearADDRESSWILLIAM A JENSEN Sup I of Bu rInq LOCALITYNEARESTFOR APPLICANT TO FILL IN CRDssTLEGAL ` OWNERDESCRIPTION LOT NBLOCK TRACT MAIL
ADDRESS
NO OF LDGS
SIZE of LOT NOW ON LOT CITY
USE OF
BUILDINGS DISTRICT NO GROPPI MAP PR BY
K P6
CONTRACTOR I '1A
t Q leLQ
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
No I DESCRIPTION OF _WORK FEE
HOUSE SEWER CONNECTING TO ,,�
PUBLIC SEWER I. 00 L TYPE OF CONNECTION LENGTH FROM
SEPTIC TgNK SEEPAGE PIT OR 4
PITS AND/OR DRAINFIELD @ SS 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD I >-
EXTN CESSPOOL DRYW ELL
S2 00 CL
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO / JOB NO U
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER sl 00 TRUNK PERMIT NO ROAD PERMIT NO
SEREPAIR
IIRRAN HOUSE @ STATE ENCROACHMENT F-
SEWER RDO SYSTE $I00 PERMIT NO V
W
INDUSTRIAL d
WASTE APPROVAL N
CHARGES ?
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEE
UTHORIZ MN TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N&MED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED Ei(ISTING DWELLING APPROVALSDATE, INSPECTOR S SIGNA)rUltE
TO THE PUBLIC SEWER
SIGNED THIS DAY 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL °
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY TH I AM PROPERLY REGISTER AND/OR DISCONNECT PLUG AND
LICENSED AS REQU R LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T 1 M THE LEGAL OWNERgFE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESID 1 ROPERTY
SIGNATURE SEEP PITS ❑ CESSPOOLS
OF PERMITTE / ��
VALIDATION ROBERT A WOOD
CKY 0 CASH SUPERVISING MECHANICAL ENGINEER
b„ 243 0 � 70 r