HomeMy Public PortalAbout5026 FIESTA AVE_Sewer__ -80 APPLICATION FOR PERMIT
7666A64242D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS "' S.-•' f` '
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN. Supt of Building LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST,
LEGAL ...e�
DESCRIPTION LOT NO. .. OWNER
e
BLOCK TRACT l^ MAIL
i ADDRESS
t
NO.OF BLDGS. ,,,a.,,,.M...—•
SIZE OF LOT i'' 16 1} NOW ON LOT CITY TEL. NO.
USOF
BUE DINGS DISTRICT NO. O([P MAP PROCESSED BY
[GR
I BK PG
CONTRACTOR
ADDRESS f CONNECTION DATA
CITY �. - TEL.N0. STATION DEPTH
p i "'� STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ,r J d .:= LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER CO) $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC
PITS AND/OR DRAENFGELDT OR @ $3.00 Y. CURB P.L. M.L.TO P.L.
N
OVERFLOW SEEPAGE PIT,DRAINFIELD p+
EXTN..CESSPOOL.DRYWELL @ $2.00 U
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO. a
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. P.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM IR OR ABANDONHOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO. A~
INDUSTRIAL O
WASTE APPROVAL P.
CHARGES
F
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA 0.l 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ip�f-� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
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 DISPOSAL SYSTEM
1 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 THAL,`I AM THE LEGAL OWNER OF'THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) [ICESSPOOLS ❑
OF PERMITTEE ` Y
OF VALIDATION ROBERT A. WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER