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HomeMy Public PortalAbout10621 FREER ST_Sewer__ 78AB41D APPLICATION FOR PERMIT 1 s E-883 11-55 ' DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE, COUNTY ENGINEER -ADDRESS ,, (d 2� _ CASSATT D. GRIFFIN, SUP'T OF BUILDING LOCALITY I FOR APPLICANT TO FILL IN NEAREST LEGAL OWNER DESCRIPTION LOT NO. /9MAIL7 BLOCK ��S TRACT / � !�' ADDRESS —5/4-"eE / NO.OF BLDGS. CITY TEL. NO. SIZE OF LOT, NOW ON LOT USE OF AlJ BUILDINGS C� DISTRICT N0, ( GROUP I MAP BK PG CONTRACTOR (�, C S © ADDRESS .C� / E -,, CONNECTION DATA STATION DEPTH CITY ✓ Oj. �. TELgNO -� ')� MANHOLE REF EN El STATE 4, UPPER REGISTRATION NO. �/ �/ ElCOUNTY LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TOYTYPE OF CONNECTION LENGTH FROM PUBLIC SEWER @ • ,URB P.L. A.L.TO P.L. SEPTIC TANK,SEEPAGE PIT IOR f PITS AND/OR DRAINFIELD Q $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO. EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $ 2.00 CO. P. NO. JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO, ROAD PERMIT NO. CONNECT ADDITIONAL BLDG.OR- STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1 00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL - CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 00 AUTHORIZATION TOTAL FEE /; REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTORSSIGNATURE TRACTOR TO CONNECT THE ABOVE DESC IBED EXISTING DWELLING TO THE PUBLIC SEWER. )r NEW HOUSE SEWER SIGNED THIS DAY OF /v 19 d CONNECT ADDITIONAL SIGNED THIS-DAY/ OWNER OR ,cam BUILDING OR WORK OWNERS AGENT ` SEPTIC TANK,SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD - I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM - I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED- AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR T T LM THE LEGAL OWNER OF THE ABOVE DESCRIBED OR RTY, BACKFILL SEPTIC TANKS❑ SIGNATURE - SEEP. PIT(S) ❑ CESSPOOLS❑ OF PERMITTEE amammucom JOHN A. LAMBIE, COUNTY GINEER VALIDATIO ROBERT A. WOOD, CHIEF PLBG. INSPECTOR CK. N. 0. CAS - - LAP-1 8 9 06R Jm161 0 A 3:00