HomeMy Public PortalAbout10723 FREER ST_Sewer__ CE608 10-63
76A642D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FR
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building '
711-
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO OWNER
i 3�o l3 MAIL
BLOCK TRACT ADDRESS �
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL .NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS ,,••++''
CONTRACTOR ' ' �•^O l- L_ �BK 5 7 C-7
ADDRESS &or •� J, ((,� CONNECTION DATA
CITYTEL. NO
�/ �• STATION 3 4 � DEPTH
` ATE MANHOLE REFERENCE
REGISTRATION NO � J /' ❑ COUNTY S �_ LOWER
NO DESCRIPTION Or WORK FEE TYPE OF CONNECTIO LENGTH FR M
HOUSE SEWER CONNECTING TO Y CURB .L M L.TO P.L }
PUBLIC SEWER @ $5.00 PC NO. a,
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 51000 CO.IMP. NO JOB NO. O
V
HOUSE SEWER CONNECTING TO TRUNK PERMIAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3.00 cz
CONNECT ADDITIONAL BLDG,OR /'► AFFIDAVIT WAIVER EASEMENT E RD INSTR NO DATE O
WORK TO HOUSE SEWER @ $3 00 (/ V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL,MAN HOLE @ E5 00 a,
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING CL
SEWER OR DISPOSAL SYSTEM @ E3 00 STATE ENCROACHMENT z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT !I z 00
AUTHORIZATION TOTAL FEE D CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCR ED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF f94�1
OWNER OR NEW HOUSE SEWER
OWNERS AGENTr
CONNECT ADDITIONAL df)–'r N
BUILDING OR WORK Y ] �
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
LRESIDE
LUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
CENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
ALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
GNATU RE - [ � BACKFILL SEPTIC TANKS ❑
OF PERMITTEE AC�` SEEP.PITS) ❑ CESSPOOLS ❑
LIDATION ROBERT A. WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
Lj,C;0 4'.;0.,2 4`7 SEP 21 1 o D 5.0 0- IN Iq