HomeMy Public PortalAbout4817 FIESTA AVE_Sewer__ D
S&E 6831189 �! Y APPLICATION FOR PERMIT
9&E 8
DIVISION OF`BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS ,
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
y
FOR APPLICANT TO FILL IN TT CROSS ST
LEGL
DESCRIPTION LOT NO /.3 f T OWNER
MAIL
BLOCK TRACT I 3J 9 ADDRESS
NO L
SIZE OF LOT ' NOWOONBLOTS CITY Cij)ZTj L NO Lj!�, o
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR 6 w
2, 4, 9
ADDRESS v
v` CONNECTION DATA
dam'
STATION DEPTH '
CITYJ. C EL NO �` � MANHOLE REFERENCE / UPPER
❑ STATE
REGISTRATION NO COUNTY
NO DESCRIPTION OF WORK FEE
/ HOUSE SEWER CONNECTING TO �. TYPE OFC NECTION LENGTH FROM
5
PUBLIC SEWER @ $3 SO O Y P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL
HAR
CONNECTION CHARGE FEE
OWNER S PERMIT s 1 00
AUTHORIZATION TOTAL FEE q REIMBURSEMENT F
V APPROVALS DATE INSP CTOR SSIGNATURE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 5 ��
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
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
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT-1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC
SEPTIC TANKS❑
❑ CESSPOOLS
SIGNATURE SEEP PIT(S)
OF PERMITTEEC
JOHN A LAMBIE COUNTY ENGINEER V VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Id O CASH
C�C3 1 8 3L FEB 20 4 450 10
C 0�