HomeMy Public PortalAbout9156 FORTSON DR_Sewer__ 7 3� 5 /V to CT /V� 5&E-66 1254 APPLICATION FOR ,PERMIT � ]�
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL .,
Department of County Engineer _
County of LOS Angeles BUILDING
WM. J. FOX, COUNTY ENGINEER ADDRESS (jJ /�
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' CASSATT D:GRIFFIN, SUP T OF BUILDING �LOCALITY .��/� ,NEAREST
G �
FOR APPLICANT-TO FILL IN CROSS ST.
LEGAL4_6 _
DESCRIPTION LOT NO _ OWNER
BLOCK TRACTS MAIL .-
J -,.q`,�✓� ADDRESS I
SIZE OF LOT t ,'NC
NOW ONBLOTS v C TEL
USE OF
BUILDINGS �Y q,. � Le(..1 LN"
DISTRIC�NO. GROUP MAP
-� 5 U .- I -A BK PG
CONTRACTOR d I , °
ADDRESS Ir 1,13 E",o—U- ,-rt °, W CONNECTION DATA '
r / TEL 0 J a STATION 4- DEPTH
/ ATE / ^MA REFERENCE
REGISTRATION NO ����/ iii ❑ COUNTY S I UPPER
j^Z % TYPE OF CONNECTLENGTH FROM
NO DESCRIPTION OF-WORK FEE Y CURB P L M L TO P.L [�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3 50 e to e!y
HOUSE SEWER CONNECTING TO 1
_ PRIVATE DISPOSAL SYSTEM 1 00
,CONNECT ADDITIONAL BLDG OR CO IMP NO. �i�V/ JOB NO _
_ WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM ' 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT OND ABANDON SEWER STATE ENCROACHMENT
_ AND/GR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ ,PITS AND/OR DRAINFIELD 2 00 'INDUSTRIAL
CESSPOOL- DRYWELL �WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE-FEE_ -
OWNEiS PERMIT S 1 00,
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
_ 4
1 HAVE THIS DATE CONTRACTED WITH TH HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCR D EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC S W R
- /SIGNED THIS NEW'HOUSE,SEWER 2� dQ � Of
� AY F 13
CONNECT ADDITIONAL
OWNER- OR
OWNERS AGENT BUILDING OR WORK
ADDRES SEPTIC TANK,"SEEP, PIT($)
• AND/OR DRAINFIELD
'THEREBY ACKNOWLEDGE THAT P HAVE READ TH 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 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-1 AM THE LEGAL OWNER 0 THE ABOVE
DESCRIBED RESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S) ❑ CESSPOOLS S f
SIGNATURE -
OF PERMITTE IN
- - - - '-
WILLIAM J.,FOX,,COUNTY ENGINEER VALIDAnON ,
Br - �.s�a5 8 9 5'� JUL 2•t 4
-BY _
3 DEPUTY •`• 1 DEPUTY -
t BY By
® DEPUTY
�IEPU
76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT CU'1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY '-
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL
DESCRIPTION LOT NO. OWNER J,
MAIL
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT j/ NOW ON LOT CITY ! TEL. NO.
USE OF
BUILDINGS BK P,DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR .
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO. CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
CO.IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ f10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. }.
PRIVATE DISPOSAL SYSTEM 53.00 CL
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEII EASEIIEYT RECORD. INSTR.NO. DATE CD
J WORK TO HOUSE SEWER @ $3.00 C')
OVERFLOW SEEPAGE PIT.DRAINFIELD LLJ
_j
EXTN..CESSPOOL.DRYWELL. $5.00 J
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING V..
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. Q
-- LC
- INDUSTRIAL CDWASTE APPROVAL D_
CHAR,CSES
-
OWNER'S PERMIT s 3 00 w
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT '
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S) '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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 Cl DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL I FCANIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE r
OF PEQMTTTEE_ - l BACKFILL SEPTIC TANKS ❑
SEEP.PIT(5) ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH
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