HomeMy Public PortalAbout4526 FIESTA AVE_Sewer__ E 6D
S$ APPLICATION FOR PERMIT
s E eDIVISION OF BUILDING AND SAFETY SEW E R—SEWAG E-D I SPOSA L
Deportment of County Engineer
County of Los Angeles
LADDRE
GSJOHN A LAMBIE COUNTY ENGINEER
CASSATTD GRIFFIN SUPTOFBUILDING Y .�
FOR APPLICANT TO FILL IN ceoss sr
LEGAL OWNER `��/ L J�7 it
DESCRIPTION LOT NO
BLOCK TRACT MAILADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NOZ�
USELDFNGS DISTRICTS GROUP MAP
14, BK PG
CONTRACTOR �'', �� � �. �
ADDRESS � CONNECTION DATA
� STATION Of a DEPTH
CITY�� �� o,EL NO ��- C>
MANHOLE REFERENCE
PPER
REGISTRATION NO / j h % ❑ COUNTY
No DESCRIPTION OF K FEE WOR
/ HOUSE SEWER CONNECTING R TYPE OF TION LENGTH FROM Jr
/ PUBLIC SEWER @ $3 y0 L� O Y CURB P L M L TOP L
i
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 p..
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 PERMIT $ 00
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE lao
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 SE WS@ NEW HOUSE SEWER
SIGNED THIS DAY OF Off-,?� 19
CONNECT ADDITIONAL
OWNER OR --BUILDING OR WORK
OWNERS AGENT ySEPTIC TANK SEEP PIT(S)
ADDRESS / +�G P c/- AND/OR DRAINFIELD "
1
I HEREBY ACKNOWLEDGE THAT I 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
I HEREBY CERTIFY THAT I 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 RESIDENTIAI.,�PROPERTY a BACKFILL SEPTIC TANKS❑ I /
SIGNATURE
�L��//// /wJ J//% SEEP PIT(5) El CESSPOOLS r r
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK E! 0 CASH
5 4 9 6m OCT 610 A 5 '00 ;� -