HomeMy Public PortalAbout10256 FREER ST_Sewer__ 42`D 1°_63
76A66A642 - APPLICATION FOR PERMIT .
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 0 ,may /'
JOHN A. LAMBIE, County Engineer ADDRESS J
WILLIAM A. JENSEN, Sup't of Building � 4r
LOCALITY '
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO OW /
MAIL � / �� /,
BLOCK TRACT � ADDRESS � C
NO OF BLDGS -
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG�i
CONTRACTOR V Y J
ADDRESS / V VVV CONNECTION DATA
CITY ( TE STATION , / DEPTH
TATE G1' ((J UPPER
REGISTRATION NO z�2�' ❑ COUNTY MANHOLE REFERENCE r�% Qa,�....�
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P.L
PUBLIC SEWER @ S5 00
SEPTIC TANK,SEEPAGE PIT OR PC
NO
CO IMPNOJOB NO �G` 0
PITS AN OR DRAINFIELD @ S1000 . .
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @° S3 00 I=
CONNECT ADDITION AL BLDG OR AFFIDAVIT wAIV[R I EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL MANHOLE @ S5 00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE 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_ � ,0
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1,HAVEREAD 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 [I DRYWELL ❑
I HEREBY CERTIFY T T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQU D BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T T AM THE LEGAL 4*;;7;4
TSCONNECT PLUG AND
RESIDE IN, TH BO DESCRIBED ANDON HOUSE SEWER
SIGNATURE CKFILL SEPTIC TANKSOF PERMITT EP,PIT(S) ❑ CESSPOOLS ❑
VALIDATI ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
L& 1'2 2 9%--or JUL 13 1 0 D 7.0 01-