HomeMy Public PortalAbout10616 FREER ST_Sewer__ 78A842D
caeoe e.e>t- APPLICATION FOR MIT
. .
COUNTY OF LOS ANGELES SEWER-SEWA E DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDISNG r
- JOHN A. LAMADORE S
BIE, County Engineer -
CASSAIT D. GRIFFIN, Supt of Building LOCALITYNEAREST
J
FOR APPLICANT TO FILL IN
CROSS ST. G4..
LEGAL ,
DESCRIPTION LOT NO. OWNER If
!�Z^�
BLOCK TRACT / MAIL
ADDRESS
SIZE OF LOT D APO N0.OF BL
NOW ON LOT
CITY TEL. NO.
USE OF
BUILDINGS DISTRICT N0. GROUP I BK MAP PG I PROCESSED BY
CONTRACTOR
ADDRESS C NNECTION DATA -- -
CITY - TEL.NO.A b ( ��y� STATION � DEPTH �.
( / / STATE MANHOLE REFERENCE
REGISTRATION NO. / 7 / ® COUNTY �� /C� OWER''
No. DESCRIPT ON OF WORK FEE
HOUSE SEWER CONNECTING TO '�
PUBLIC SEWER c- $5 00 � �
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. �3L —
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.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS - DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR ^� CONNECT ADDITIONAL C `
OWNERS AGENT—�z 2 ( BUILDING OR WORK
ADDRESS SEPTIC'TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE 1 L PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S ❑ CESSPOOLS ❑
OF PERMITTE
®" VALIDATION ROBERT A. WOOD
CIL It.o. GABA J SUPERVISING MECHANICAL ENGINEER
Uig_ y 1 '� �/i a iCtiV ! .0' �� j