HomeMy Public PortalAbout10531 FREER ST_Sewer__ ' 4--
76A64 40a,,0_B2 APPLICATION FORPT
78A842D - I I
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Iul
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDISNG S
-JOHN A. LAMHIE, County Engineer ADDRE
WILLIAM A. JENSEN, Sup'1 of Building �f" `�
_ LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL
DESCRIPTION LOT NO /` OWNER eOWel
MAIL
BLOCK TRACT �7.2�0
ADDRESS
NO. OF BLDGS
SIZE OF LOT NOW ON LOT 34 CITY �� (:j. TEL -NO.
USE OF �y`
BUILDINGS �Ls�iV�/��i� DISTRICT NO GROUP MAP PROCESSED BY
PG
CONTRACTOR /✓ (�'O�"�s�j`�1 Cao• ! y'
'ADDRESS O fi40 ,ti r� C NECTION ATA
CITY//'!!J/haQ1Q TEL NO 44%0— v"� ION ;.j�' DEPTH
REGISTRATION NO i6 esm'¢¢ ❑ COUNTY MANHOLE REFERENCE ' (jj_J! d UPPE
NO. DESCRIPTION OF WORK FEE T P1E OFC C O ENGTH FRO
HOUSE SEWER CONNECTING TO IY/ A C P M.L TOP L. ,� O
PUBLIC SEWER @ $5.00 —!5r OO i
[///111 pC NO. (�
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO. C .108 NO
PITS AND/OR DRAINFIELD @ STOOD
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $300 _
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR NO DATE IVL
WORK TO HOUSE SEWER @ $300 d
OVERFLOW SEEPAGE PIT,DRAINFIELD h
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $500 HWY OR ST WIDENING
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i 00 CHARGES
AUTHORIZATION TOTAL FEE O CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- - REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE��
SIGNED THIS D OF 19_ _
OWNER OR 'I,- NEW HOUSE SEWER
OWNERS AGENT '// (i�/ �� /1/aF�! 4 � ��J✓
CONNECT ADDITIONAL C
• - BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
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 STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT A THE LEGAL OWN OF, AND INTEND TO DISCONNECT PLUG AND
SIGNATURE THE AB E SCRIBED REy'q TIA PROPERTY
/`Y// ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS.❑
OF PERMITTE ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
LAU0 4 1 7 2 ZO JAN 7 10 D 7.0 0
s f.I '
CE808 10-82
76AB420- APPLICATION FOR PERIT -
COUNTY OF LOS ANGELES SEWER—SEWAGE
DEPARTMENT OF-COUNTY ENGINEER DISPOSAL
BUILDING AND SAFETY DIVISION '
BUILDING
JOHN A. LAMBIE, County Engineer S �i✓-��— r�'�r"
WILLIAM A. JENSEN, Sup't of Building
Y � T
FOR APPLICANT TO FILL IN 5T L p p t
LEGAL / �Q//� .G y�G
_DESCRIPTION LOT NO OWNER I7 QIY
MAIL
I BLOCK 4s/ TRACT ADDRESS
NO OF BLDGS.
SIZE OF LOT NIOW ON LOT CITY �� TEL. NO.
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
" ✓�W G�G
B�KI PG
CONTRACTOR��L� .(��/"'�Q`J�J (r •� C", ./) / I �p//
ADDRESS 3 n /Q" .!�•� �Q CO NECTION DATA
CITY/I��L�I���/C� TEL NODEPT.
f/ 2O,0¢ STATE
/(p UPPERS
REGISTRATION NO ✓ ❑ COUNTY MANHOLE REFERENCE
�� + d
NO DESCRIPTION OF WORK FEE TYP OF CO NECT ON 'LENGTH F OMO
HOUSE SEWER CONNECTING TO Y. M L TO P.L.
PUBLIC SEWER @ $5.00 / 1 p.0 NO.
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO. / " POB NO O
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECTADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR NO. DATE d
WORK TO HOUSE SEWER @ $3.00 H
OVERFLOW SEEPAGE PIT,DRAINFIELD Z
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $5 00
ALTER,REPAIR OR ABANDON HOUSE
HWY OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 _ STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL E
WASTE APPROVAL
OWNERS PERMIT S _ - CHARGES
AUTHORIZATION TOTAL FEE 0_0 CONNECTION CHARGE FEE
1 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 19_
OWNER OR - - NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS - BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
]-HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO ESCRIBED' L PROPERTY _ ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP.PITS) ❑ CESSPOOLS ❑
OALIDATION _ ROBERT A. WOOD
M O CASH
SUPERVISING MECHANICAL ENGINEER
CK
Li iC0 4 1 7 3 JAN 7 1 1 D 2 5.0 0-