HomeMy Public PortalAbout10527 FREER ST_Sewer__ E-q63
s& 69 11.55 APPLICATION FOR PERMIT_ --
S 8 E•6 - � -
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING �f
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS `
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNE
DESCRIPTION LOT NO. f '
MAIL f
BLOCK TRACT ADDRESS/Oj_yX_b
N0.OF BLDGS. CITY
SIZE OF LOT NOW ON I.PT
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
4__ BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
l
STATION DEPTH
CITY GfEL.CO MANHOLE REFER NCE UPPER
STATE LOWER
REGISTRATION NO. �o�G�G l ❑ COUNTY -
No. DESCRIPTION OF WORK FEE _
HOUSE SEWER CONNECTING TO TYPE OF CONNE TI N LENGTH FROM
PUBLIC SEWER @ aw
Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO. '-
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. R RMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMEN
WORK TO HOUSE SEWER @ $.1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APP VAL
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT s 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO�CONNECT -THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER _
SIGNED THI DAY OF CONNECT ADDITIONAL _
OWNER OR , BUILDING OR WORK
OWNERS AGE N SEPTIC TANK,SEEP,PITS)
ADDRESS ..r AND/OR DRAINFIELD - - -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THI APPLICATI CESSPOOL❑ DRYWELL❑ -
AND STATE THAT THE ABOVE IS CORRECT AND AGR(1E TO COMPLY
WITH ALL COUNTY ORDINANCES -AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW
CALIFORNIA OR THAT 1 AM, THE!E
OF T ABOVE
ER
DESCRIBED RESIDENTI OPE Y. /A���..,►►►666BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS(]
OF PERMITTEE _
JOHN A. LAMBIE, COUNTY ENGINEER O VALIDATIROBERT A. WOOD, CHIEF PLBG. INSPECTOR
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