HomeMy Public PortalAbout5323 FARAGO AVE_Sewer__ S&E6DeAPPLICATION FOR PERMIT 1
E DMSION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engmeer
County of LOS Angeles FNEAREST
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JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING Y
FOR APPLICANT TO FILL IN
L-7
17EGAL OWNER
DESCRIPTION LOT NO �
�j q 3 MAIL
�L
BLOCK TRACT - pDDRE.S
NO OF BLDGS / CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO ( GROUP EK MAP
BUILDINGS
CONTRACTOR CZ _r: f f� P�
ADDRESS CONNECTION DATA 1 Y PPP
Q
CIT EL NO
STATION DEPTH •
AN 114k Z4 �3�J
LOWER
MANHOLE REFERENCE
REGISTRATION NO �C`�`- `_ S�.^ .y
No DESCRIPTI N OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
Y CURB P L M L TO P L
PUBLIC SEWER @ $340 O
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO JOB NO f7
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMT g 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY / I9 CONNECT ADDITIONAL r
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE / SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
;Z�_ . —
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
"ACo 8804L-14 JUL 1 1 OA 500
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