HomeMy Public PortalAbout10610 FREER ST_Sewer__ E808 0
cfieoe APPLICATION FOR P RMIT
•ea COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Lam/
ADDRESS
JOHN A. LANIBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST: A-14 4 -
LEGAL 71 ,
OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT / ! ADDRESS
{') NO.OF BLDGS.
SIZE OF LOT CJ NOW ON LOT CITY TEL. NO.
USE OF MMMMDISTRICT NO. GROU1 MAP PRO SED BY
BUILDINGSZm
I BK/ �PG
CONTRACTOR d
ADDRESCO NECTION DATA
CITY TEL.NO� llSTATION DEPTH
STATE
REGISTRATION NO {- MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
4 PUBLIC SEWER @ $7.00 ` l
YPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN .CESSPOOL DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. '
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
WORK CONNECT HOUSE ADDITIONALSEWELDG.OR @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO. 1(7 ,
ALTER, REPAIR SPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
_ WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE ) REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS D9TE, INSPECTOR'S SIGN9T)•1RE_
TO THE PUBLIC SEWER.
-SIGNED THIS DAY OF 19_ NEW HOUSE SEWER 11O/-
O •�� -e9 CONNECT ADDITIONAL
OWNERS AGENT
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
LDESCRIBED
EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CgRRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL El
LL COUNTY ORDINANCES AND. STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
G AND SEWERS. .J SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
NIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
ED RESIDEN 1 PROPERTY. BACKFILL SEP❑ CESSP00LSREMITTE +�
®p VALIDATION ROBERT A. WOOD
CIL M.C. CASH SUPERVISING MECHANICAL SN6INEER