HomeMy Public PortalAbout4844 FIESTA AVE_Sewer__ :E808 3 62
78A642D APPLICATION FOR PERMIT
A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FU
DING
JOHN A LAMBIE COUNTY ENGINEER ESS 104 eV
COLEMAN W JENKINS SUP T OF BUILDING 7
LITY
EST
FOR APPLICANT TO FILL IN S ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY L NO
USE OF
C64I
BUILDINGS DISTRICT NO UbROUPI If MAP PROCESSED BY
_ BK PG
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CONTRACTOR ` �(d •� 94t
ADDRESS ,� CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE �r MANHOLE REFERENCE UPPER
LICENSE NO CLASS C..� F� LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P L a
PUBLIC SEWER @ S5 00 PC NO O
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO oe
PRIVATE DISPOSAL SYSTEM @ S300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEREASEMENT RECORD INSTR NO DATE I,
WORK TO HOUSE SEWER @ $300 U
OVERFLOW SEEPAGE PIT DRAINFIELD LLI
EXTN CESSPOOL DRYWELL MANHOLE @ 35 00 d
ALTERi� FDHOUSE HWY ORST WIDENING Z
SEWER OGGA4 SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s i o0
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF I9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR '' F��'/
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM x
CALIFORNIA OR THAT I AM THE LEGAL OWNE OF AND INTEND TO DISCONNECT PLUG AND v N
RESIDE IN THEA DESCR ED RESIDEN IAL PROP Y ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
K M O A H
�5 5 4 4•o JUL19 1 U D 5,00- a