HomeMy Public PortalAbout10236 FREER ST_Sewer__ i
10-63
76A6426A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS to
WILLIAM A. JENSEN, Sup't of BuiIdmg
LOCALITY
NEAREST
FOR APPLICANT O FILL IN `ROSS
LEGAL
DESCRIPTION LOT NO OWNER
MAIL 001,
BLOCK TRACT ! ADDRESS
40OF BLDGS
SIZE OF LOT NOW ON LOT CITY H TEL NO
USE OF DISTRICT NO GROUPEIK MAP PROCESSED BY
BUILDINGS !'
CONTRACTOR �/V X J P� ^ ��
M zz
ADDRESS 'y CONNECTION DATA
CITY
STATION " DEPTH
TEELL�
REGISTRATION NO �.dV _�.♦' ❑ CTATE
'` UPPER
MANHOLE REFERENCE
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB L M L TO P L
PUBLIC SEWER C $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR L. O
PITS AND/OR DRAINFIELD C 51000 CO IMP NO UOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W�IVEN EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN'C E SSPOOL,DRYWELL MANHOLE @ $5 00 a_HWY OR ST WIDENING h
ALTER REPAIR OR ABANDON HOUSE Z
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z"00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO 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
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING [:1PLUMBING AND SEWERS CESSPOOL ElDRYWELL
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS RE E BY LOS AN COUNT D STATE OF SEWA GE DISPOSAL SYSTEM
CALIFORNIA OR AT AM THE LEG OWN O , A D INTEND TO DISCONNECT PLUG AND
RESIDE IN, T AB E DESCRIBE ID I PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMI SEEP,PITIS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
'
CK M o CASH SUPERVISING MECHANICAL ENGINEER
1 2 3 3% JUL 13 1 0 0 7.00-