HomeMy Public PortalAbout10250 FREER ST_Sewer__ i
A86�0-63 APPLICATION FOR PERMIT w
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt o4 Building r
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL 1100,
BLOCK TRACT ADDRESS . C
O OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG//
CONTRACT O `/ �
ADDRESS CONNECTION DATA
CITY _ TEL STATION DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY f LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB L I M.L TOP L.
PUBLIC SEWER C� $5 00
SEPTIC TANK,SEEPAGE PIT OR P.0 N0. O
PITS AND/OR DRAINFIELD @ $10 00 CO IMP. NO JOB NO G• V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT w=RECORD RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER C $300 V
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN„CESSPOOL,DRYWELL,MANHOLE @ $5 00 d
ALTER.REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN-NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E) ING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 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 STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIgTIAM PROPERLY REGISTERED AND�OR ALTER,REPAIR,SEWER OR
LICENSED AS REQLOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TTHE LEGAL O OFAND INTENDTO DISCONNECT PLUG AND
RESIDE IN, THE CRIBED R TIA ROP TY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE BACKFILL SEPTIC TANKS ❑
- (S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
CK M o ASH SUPERVISING MECHANICAL ENGINEER
1 2 3 om JM13 1 0 D 7.00N