HomeMy Public PortalAbout10240 FREER ST_Sewer__ P -
10-63 APPLICATION FOR PERMIT
T
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCROSS
ING
JOHN A. LAMBIE, County Engineer ESS ,
WILLIAM A. JENSEN, Sup t of Building ! _
LiTV ,
EST
FOR APPLICANT TO FILL IN 5T
LEGAL ` Ar
_DESCRIPTION LOT NO J OW
MAIL
BLOCK TRACT
ADDR
NO OF BLDGS
SIZE OF LOT NOW ON LOT *�74ATE
rDISTRICT
r TEL NO
USE OF
BUILDINGS NO GROUP MAP PROCESSED BY
SK PG
CONTRACTOR
ADDRESS -�/ CONNECTION DATA
DEPTH
CITY TEL'REGISTRATION NO E REFERENCE UPPER
�f}�� ❑ COUNTY Z /,J�� L
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L >'
PUBLIC SEWER @ $5 00 d
SEPTIC TANK SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO -LJ U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WIPER EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $300 U
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 1 a
ALTER REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
I PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE } CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONN REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS OF 1
NEW HOUSE SEWER
OWNER OR to ' j�Y+✓W'✓I I P
OWNERS AGENT
CONNECT ADDITIONAL [p
BUILDING OR WORK �P
ADDRESS
SEPTIC TANK SEEP PITtS)
I HEREBY ACKNOWLEDGE THAT I 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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY, A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T AM THE LEGAL R OF EVINTEND TO DISCONNECT PLUG AND
RESIDE IN THE E DESCRIBED R NTIA OPERTY ABANDON HOUSE SEWER
SIGNATURE _ I BACKFILL SEPTIC TANKS ❑
OF PERMITTE IT(S) ❑ CESSPOOLS ❑
VALIDATIq "1 ROBERT A wood
cK M o CASH SUPERVISING MECHANICAL ENGINEER
1 23 2 JM 13 1 0 D 7.0 0'- W.