HomeMy Public PortalAbout10246 FREER ST_Sewer__ 6A64 2D 10-63
76A64APPLICATIO FOR PERNOKT
lJ
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OW NE
MAIL
BLOCK TRACT ADDRor
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
BK
CONTRACTOR PG
CONTRACTOR
ADDRESS '� -� / ✓ fffJJJ CONNNECTION DATA
STATION DEPTH
'ED STATE
REGISTRATION NOI p C/ ❑ COUNTY MANHOLE REFERENCE �t ^ UPPER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P L. ML TO P L 3
PUBLIC SEWER @ $S 00
P C NO d
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/ DRAINFIELD @ $10.00 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300 w
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVEN I EASEMEMT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT L••
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
I HAVE 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 Y t 1
OWNERS AGENT CONNECTADDITIONAL U
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP,PITS)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUI BY LOS ANGLES COUNT STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T 1 AM THE LEGA NER OND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH BO DESCRIBED DENTI ROPERTY
ABANDON HOUSE SEWER
SIGNATURE 01
OF PERMI / BACKFILL SEPTIC TANKS ❑
EEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M O CASH
L& 1 2 3 1%-D-1 JUL13 l o o 7.00IN
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