HomeMy Public PortalAbout5336 FARAGO AVE_Sewer__ r
CE80811157 APPLICATION FOR PERMIT �-
CE80B 8
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL_ �
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAIIBIE County Engineer ADDRESS
CASSAIT D GRIFFIN Supt of Building I LOCALITYFOR APPLICANT TO FILL IN CROSS sTLEGALDESCRIPTION LOT NO OWNER
BLOCK TRACT ADDRESSMAIL
a +
k NO OF BL GS
SIZE OF LOT ~ v NOW ON LOT CITY TEL'NO r
USE OF
BUILDINGS " t I DISTRICT NO I GROUP I B MAPrP
CONTRACTO
ADDRESS 3 4! v7 }� CONNECTION DATA
CITY �.,_ TEL NO Job, h G STATION / DEPTH
REGISTRATION NO
j� *-:1, 4 STATECOUNTY MANHOLE REF ENCS
LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @
S SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTI LEN GTHTOP FROM
CURB M L L
!
y P L
PITS AND/OR DRAINFIELD @ $3 00 e
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO.I 0
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
+ ; WASTE APPROVAL
CHARGES
OWNER S PERMIT $ It 00 CONNECTION CHARGE FEE
AUTHORIZATION 'TOTAL FEE` 'n
REIMBURSEMENT FEE
I HAVE AT THIS DATE A-CONTRACT WITH THE-HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECT R S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS J�JDAY OF _ )9- NEW HOUSE SEWER '/ �1�•� /i � ie���
OWNER OR CONNECT ADDITIONAL-
OWNERS AGE NT�_L��+- BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS - w 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 REPAIR
DISPOSALSEWER
OM.-
1 HEREBY CERTIFY THAT-I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNERTHE ABOVE ABANDON HOUSE SEWER El _
DESCRIBED RESIDE N IAL PROP Y BACKFILL SEPTIC TANKS
SIGNATURE ' -•1 SEEP PIT(S) [] CESSPOOLS El
OF PERMITTE ^ y
VALIDATION ROBERT A WOOD`
CK H o CASH SUPERVISING MECHANICAL ENGINEER
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