HomeMy Public PortalAbout10651 FREER ST_Sewer__ CEA - APPLICATION FOR PERMI
76A6420 42D lJ
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ;PIROESSED
JOHN A. LAMBIE, COUNTYENGINEER ADDRESS OCOLEMAN W. JENKINS. SUPT OF BUILDING LOCALITY
NEARESTFOR APPLICANT TO FILL IN CRDSS 6T LEGAL �1 /DESCRIPTION LOT NO e OWNERMAIL
BLOCK TRACT ADDRESSNO. OF BLDGSSIZE OF LOT/47 X NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO GROUP MAP BY
BBK PG
CONTRACTOR
ADDRESSCONNECTTON DATA
CITY G mp C)/TNO STATION ( ` DEPTH
/ ! r
STATE LIC MANHOLE REFERENCE
LICENSE NO. CLASS j LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTI ,` ENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L. M L TOP.L
OP.L a
PUBLIC SEWER @ $5 00 (�' l/ PC NO O
SEPTIC TANK,SEEPAGE PIT OR CO IMP NOJOB NO.
PITS AND/OR DRAINFIELD @ SIO 00 . U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ E3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT w4IVE1 ESS EMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ E3 00 U
OVERFLOW SEEPAGE PIT.DRAINFIELD l!J
EXTN CESSPOOL DRYWELL.MANHOLE @ 55 00 a
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING '
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ i o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS D TE INSPE R'S SIGN T RE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER g � J
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 El '
PLUMBING AND SEWERS CESSPOOL [IDRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER.OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE,DISPOSAL SYSTEM u _
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND S
RESIDE IN, THE ABOVE ESCRIBED R IDENTIAL P OPERTY, ABANDON ❑HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMfTTEE ❑
SEEP.PIT(S) CESSPOOLS
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
I_t'E 5 6 9 5 w JUL 31 1 0 p 7.0 0