HomeMy Public PortalAbout10711 FREER ST_Sewer__ D
S&E-688 fl•S9 APPLICATION FOR PERMIT 1 -
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer ry /y
County of LOS Angeles BUILDINAD DRESS /0 / �/ ��^► 6�
JOHN A. LAMBIE, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY 77'
NEAREST
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FOR APPLICANT TO FILL IN ceoss STLEGAL 6 //
DESCRIPTION LOT NO. 7.- OWNER
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BLOCK TRACT - ADDRESSNO. OF BLDGS. CITY TEL, NO.
SIZE OF LOT- 1 NOW ON LOT
USE
BUILDINGS DISTRICT NO. GROUP BK MAP PG
4 11 CONTRACTO , ../ S _Z' 6 o ('
ADDRESS �' 'oyf " CONNECTION DATAB d--�
STATION DEPTH B
CITY i- �.• TEL. N0. d J�LJ�
j/ ®� MANHOLE REFERENCE UPPE
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REGISTRATION N N0. 14S 7 \VI C:1COUNTY O E
NO. DESCRIPTION OF WORK FEE
p HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER , @ $ _
Y Y. CURB P.L. M.L. TO P.L.
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, NO. JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL 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
OWNERS PERMIT g 00 R (g i
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS D TE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ��„ /r
TO THE PUBLIC SEWER. - NEW HOUSE SEWER PC l,Cf.(.• �
SIGNED THIS' DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY�ACKNOWLEDGE THAT I 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 T• AT I AM1 ROPERLY G1STER 9D/OR
LI, NSED AS R IR OS CO TY AN TAT OF DISCONNECT PLUG AND
CAL AT � OYE ABANDON HOUSE SEWER
DES\CMURE
EN BACKFILL SEPTIC TANKS•SIGN
SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A:LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
128• h1.0 CASH
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