HomeMy Public PortalAbout10624 FREER ST_Sewer__ E-6D
S& 68 11-99
APPLICATION FOR PERMIT �.
S E-8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer '
County of Los Angeles BUILDING ` g �lv c�� 17-,
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS < O 6�
® CASSATT D. GRIFFIN, SUPT OF BUILDING
LOCALITY t
FOR APPLICANT TO'FILL IN CROSS ST. /I
DESCRLEGIPTION LOT NO.Al, r ' -� f a a/ OWNER :F .p �, +MAILBLOCK - TRACT �--� G ADDRESSN0. OF BLDGS CITY TEL. NO.
SIZE OF LOT NOW ON LOT
USE OF >� DISTRICT NO. GROUP MAP
BUILDINGS T �-h/--o" _
BK PG
CONTRACTOR
ADDRESS ��� CONNECTION DATA
CITY- s TEL. _ �� STATION DEPTH `
MANHOLE REFERENCE •^'
❑ STA E OWER
REGISTRATION NO. X7 ❑ COUNTY
NO. DESCRIPTION OF V� FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L. TO P.L.
PUBLIC SEWER @ (�
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. NO. / P.NO
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00
PRIVATE HOUSE DISPOSALER CONNECTING TO
SYSTEM @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO.�
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER-OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
-CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE 6
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECT R'S SI GNAT U RE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING-DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER- -
SIGNED THIS DA OF 19
_ CONNECT ADDITIONAL C
OWNER OR _ BUILDING OR WORK . -
OWNERS AGENT ,
SEPTIC TANK,SEEP,PITS)
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
LICENSE AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
JDC
FO IA OR THAT I THE LEGAL OWNER OF E ABOVE E�D`RES1 IAL P PERTY. BACKFILL SEPTIC TANKS�� � SEEP.PITS) ❑ CESSPOOLS❑
ERM TEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. 61. 0. CASH -
�;10 3 5.0 0 M =
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