HomeMy Public PortalAbout10657 FREER ST_Sewer__ c
10-63
766642D . APPLICATION FOR PERM
6A64 �
COUNTY OF LOS ANGELES SEWER-SEW* -AGK DISPO AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer AD DRE55 -
WILLIAM A. JENSEN, Sup't of Building
LOCALITY L
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO �l OWNER
MAIL
BLOCK TRACTeQ
ADDRESS
NCr OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESptb BY
BUILDINGS BK PG
](�J/` /� r
CONTRACTOR J
ADDRESS ftp CONNECTION DATA
CITY ,� TEL NO f STATION O/O DEPTH
.g STATE MANHOLE REFERENCE UPPER
REGISTRATION NO �.2 Q/ ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P.L. M L TO P.L. }
PUBLIC SEWER @ SS 00 PC NO d
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/OR DRAINFIELD @ $1000 CO.IMP NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $300 \ I=
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEmiRTRECORD INSTR NO/ DATE Q
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL.MA NH OLE @ $5 00 d
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 0)
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT z
I PERMIT NO
C NDUSTRIAL
If WASTE APPRO
CHARGES
O RAS I PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHO'11IZATION I TOTAL FEE 10
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR \ NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL (V6
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑, DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED LOS ANGLES CO'NTY D STATE OF ,SEW AGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I/-/-- TIHE LEGAL�EA INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABVRIBED RESID NT P ERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
CKCALIDATION ROBERT A. WOOD
M o CASH SUPERVISING MECHANICAL ENGINEER
i}tu� 3 4 6' NAY 7 1 0 D 5.0 G