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HomeMy Public PortalAbout10605 FREER ST_Sewer__ 6A642D,°-63 76A64APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Sup't of Building �d /fes C C FOR APPLICANT TO FILL IN 7 LEGAL DESCRIPTION LOT NO � _.ry OWNER L•� MAIL BLOCK / TRACT f�/- ADDRESS NO. OF BLDGS. 3 SIZE OF LOT NOW ON LOT ACITY USE OF '� J BUILDINGS c/'w _ //`f DISTRICT NO GROUP MAP /�P/1R�O�CESS BY 9. BK PG CONTRACTOR l �_ � L7'��-'`'J�/�, [�Q. ADDRESS U CONNECTION DA IONTA CITY��'L'�i�/`f�v,/� TEL NO. / Tf DEPTH �� A� Q�STATE MANHOLE REFERENCE $ REGISTRATION NO. �/"' ❑ COUNTY ER NO. DESCRIPTION OF WORK FEE TY P OF CONECT}ON L FROM ) HOUSE SEWER CONNECTING TO ,�f@/ P L •L TO P L PUBLIC SEWER $5.00 P.C.NO. d SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $10.00 CO IMP. NO JOB NO. �I Q HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ! V PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER E�SEMERT RECORD. INSTR NO DATE O WORK TO HOUSE SEWER @ S300 U OVERFLOW SEEPAGE PIT,DRAINFIELD L1) EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5.00 \ / HWY. R T IDENI ALTER,REPAIR OR ABANDON HOUSE ( f Z SEWER OR DISPOSAL SYSTEM @ $300 STAT ROACHM NT _ PERMIT NO INDUSTRIAL WASTE APPROVAL _ OWNERS PERMIT s CHARGES AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR /// NEW HOUSE SEWER OWNERS AGENT I' CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PITS) 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 ❑ I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE RIBED RES AL��PROPERTY ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE BACKFILL SEPTIC TANKS ❑ ❑ SEEP.PIT(5) ❑ CESSPOOLS VALIDATION ROBERT A. WOOD CK. M O CASH SUPERVISING MECHANICAL ENGINEER 3 7 JAN 2 9 1 1 D 2 5.00- 0-63 76A642D APPLICATION FOR PERMIT 6A642 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING /O{�J JOHN A. LAMBIE, County Engineer ADD RE 5S WILLIAM A. JENSEN, Supt of Building — LOCALITY ���r NEAREST FK OR APPLICANT TO FILL IN CROSS 5T ION LOT NO �(L� c OWNER y�i��/ ` O•. �`�� MAIL TRACT ADDRESS /f NO. OF BLDG �.j L. NO. LOT NOW ON LOT J CITY S ' / DISTRICT NO GROUP MAP PROCESS BYBK PG rOR i'3YG y�r/ 4c� ECTIr���/'J�J'lj/TEL NO/ T ION G/ /} DEPTH REGISTRATION NO. A1C' ©¢� ❑ COUNTY MANHOLE(REFERENCE NO. DESCRIPTION OF WORK FEE TYPE OF CO E ?ION L GTH FROM ) / HOUSE SEWER CONNECTING TO Y^ P.L. L.TO P.L. / PUBLIC SEWER @ $5.00 SEPTIC TANK,SEEPAGE PIT OR P.0 NO a CO.IMP. NO PITS AND/OR DRAINFIELD @ $1000 J' JOB NO. Q HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT V PRIVATE DISPOSAL SYSTEM @ $300 5� w CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO. DATE O WORK TO HOUSE SEWER @ $3.00 V OVERFLOW SEEPAGE PIT,DRAINFIELD l!J EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5.00 ALTER,REPAIR OR ABANDON HOUSE HWY. IE h SEWER OR DISPOSAL SYSTEM @ $3.00 STATErENVROACHMENT PERMIT NO INDUSTRIAL OWNERS PERMIT WASTE APPROVAL CHARGES S 2 00 AUTHORIZATION TOTAL FEE a,D 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 APPROVALS TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY F 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL 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 WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I 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 I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE /DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIOF ATURE PERMITTEE ✓� '�•- /, BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS ❑ /^VALIDATION ROBERT( WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH so 8 0 3 6 �PtN 2 g 1 0 D 7.0 0- LA �' ,',_; r,