HomeMy Public PortalAbout10249 FREER ST_Sewer__ r
766A64A64 2 e-63 APPLICATION FOR PEF MIT
-t COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPRTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FN
LDING
IOHN A. LAMBIE, County Engineer DRES
WILLIAM A. JENSEN, Sup't of Building
ALITY
RESTFOR APPLICANT TO FILL IN 95 5T
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRE
O OF BLDGS
SIZE OF LOTNOW-ON LOT CITY TEL NO.
USE OF DISTRICT NO GROUP MAP PROCESaBY
BUILDIN /
K PG
CONTRACTOR Q�� 'S� ✓ /l S
l
ADDRESS �y CONNECTION DATA
Y TE ION -7 DEPTH
h ATE MANHOLE REFERENCEUPPER
REGISTRATION NO 'J COUNTY D •.LOQ^
NO DESCRIPTION OF WORK FEE TYPE OF CON NECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P.L. }
PUBLIC SEWER @ $5 00 PC NO. d.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. L O
PITS ANDOR DRAINFIELD @ $10 00 CO IMP. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT.DRAINFIELD L!J
EXTN,CESSPOOL,ORYWELL.MANH.LE @ $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 MIT $ 2 OoAUTHORIZATION[PER
TOTAL FEE 1 CONNECTION CHARGE FEE CHARGES
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 19_ / ���,,(({{,, �q,(/f/}�
OWNER OR NEW HOUSE SEWER !(1 '/+ (?-044` "•(`may r'(Y
OWNERS AGENT t./
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(5)
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 ST LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL [:1 DRYWELL ❑
I HEREBY IFY THAT I PR RLY REGISTE ED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AY"REbUIRED BY LO LES COUNTY ND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNI OR HAT 1 AM THE LE L NER O AND INTEND TO DISCONNECT PLUG AND
RESIDE If, TH ABOVE DESCRIB RESIDE PROPERTY ABANDON HOUSE SEWER
SIE
OF P 0 ILL SEPTIC TANKS E]OF P SEEP,P (S) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
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