HomeMy Public PortalAbout10239 FREER ST_Sewer__ 6A64 10-63 APPLICATION
PPL ICA TION FOR P�°R�i
76A642D i� d� �oP1 ��Q e�
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
F-E
GAL
IPTION LOT NO. OWNER
MAIL
TRACT ADDRESS Q
NO. OF BL S. -7P6
OF LOT NOW ON LOT CITY 1 � TEL. NO.
F DISTRICT NO. GROUP MAP PR ESSED BY
NGS 4
PG
CONTRACTO i/�✓ 'J ,S /`�' �-�-y
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ADDRESS CONNECTION DATA
CITY TE STATION + DEPTH
TATE { UPPER
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE .! 11� �cp"IrR—
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.,.) M.L.TO P.L. L �
PUBLIC SEWER @ S5.00 _
SEPTIC TANK,SEEPAGE PIT OR P.C. NO.
PITS AND DRAINFIELD $10.00
CO.IMP, NO. JOB NO. O
HOUSE SEWER CONNECTING TO - TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR x AFFIDAVIT WAIVEq EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL.MAN HOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 Oo CHARGES
AUTHORIZATION I TOTAL FEE j CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �y
TO THE PUBLIC SEWER. APPRO tlALS DATE INSPECTOR'S SIGNATURE.
SIGNED THIS Y 19_ / 7
OWNER OR NEW HOUSE SEWER 10-f
OWNERS AGENT -
CONNECTADDITIONAL �
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH M THE LEGAL O ER OF, A NTEND TO DISCONNECT PLUG AND
RESIDE IN, THE V DESCRIBED R ENTI P PERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
7'L/