HomeMy Public PortalAbout10676 FREER ST_Sewer__ • r
76AS420 11-95
8& - APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—S MAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING r` o� �� ��
ADDRESS ! 6j ,s�,
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO. FILL IN CROSS ST. t;4
�..
LEGAL OWNER4ged&c
DESCRIPTION -LOT NO. - 1 G,?
MAIL
BLOCK - TRACT ADDRESS
.' NO. OF BLDGS.
SIZE OF LOT �.. NOW ON LOT QI[. CITY -�^• _ TEL. NO.
Uam
SE OF �G,, G DISTRICT NO. GROUP MAP
BUILDINGS �!(�c�Lf:L K PG
CONTRACTOR _
T ADDRESS 4 CONNECTION DATA
c STATION O, DEPTH
CITY a„ �/ �� TEL. NO./+
MANHOLE REFERENCE p UPPE
1 2 STATE S LOWER
REGISTRATIO NO. A ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB .L. - M.L.TO P.L.
Y PUBLIC SEWER @ $3.50 _
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD - + P. C. NO.
EXTN ,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO. IMP. N0, C. � JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE-DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT j�—
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 $ 1 00 a
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON- '' APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SEWER I � //ff"� �--y NEW HOUSE SEWER
SIGNED THIS DAY OF_:!��J Gl2 19 Ste% ; CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
/ �•
ADDRESS a .1ZfY AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ 1 IS APPLN ICATI CESSPOOL E3DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS GULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
_ I HEREBY CERTIFY THAT I AM PROPERLY $E ISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGEL'E ,0'UNTY AND STATE OF ABANDON•HOUSE SEWER
CALIFORNIA OR THAT ,ICh1 THE L•EG MER OF T E ABOVE /
DESCRIBED RESIDENTI ROPERTY. BACKFILL SEPTIC TANKS[ISIGNATURE y SEEP. PIT(S) ❑ CESSPOOLS �y
i
OF PERMITTEE •% °'�
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JOHN A. LAMBIE, G6 TY ENGINEER // VALIDATION ROBERT A WOOD, CHIEF PLBG. INSPECTOR
e� CK. M. 0. (CAS
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