HomeMy Public PortalAbout10777 FREER ST_Sewer__ 8A642)o.82
7 " APPLICATION F R PERMIT
78A 842
' COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING D a.�
JOHN A. LAMBIE, County Engineer ADDRESS /
WILLIAM A. JENSEN, Sup't of Building
LOCALIT
NEAREST
FOR APPLICANT TO FILL IN `Ross ST,
LEGAL '
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT '7'�U � ADDRESS b 7
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
ISUILDINGS
�I BKS PG
CONTRACTOR �V •� r�.I
-•..�I i�r I s
y ADDRESS CONNECTION DATA-
ST-N
ATASTA N DEPTH
CITY
I STATE MANHOLEUPPER
REGISTRATION NO /3 o�S ❑ COUNTY ENCE
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P.L. M.L TOP L. O
PUBLIC SEWER @ $5 00 - % P, O V
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 C
HOUSE SEWER CONNECTING TO R WIVE/MI PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ 3300 (—
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RE(fORDF INSTR NO. DAT U
WORK TO HOUSE SEWER @ $3.00 Q.
OVERFLOW SEEPAGE PIT,DRAINFIELD H
? EXTN,CESSPOOL,DRYWELL,MANHOLE @ $500 Z
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
S PERMIT NO
.INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
I
NNEC ON CHARGEFEE
AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED EIMBURSEMENT FETRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWETOTHE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THISn DAY OF 1OWNER OR . W HOUSE SEWEROWNERS AGENT NNECT ADDITIONALADDRESS ILDING OR WORKEPTIC TANK,SEEP,PIT(S)IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICAND�OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COWITH ALL COUNTY ORDINANCESAND STATE LAWS REGULPLUMBING AND SEWERS SSPOOL ❑ DRYWELLIHEREBY CERTIFY THAT IAM PROPERLY REGISTERED ANLTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BYLOS ANGLES COUNTY AND STATE WAGE DISPOSAL SYSTEM
.CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, ND INTENISCONNECT PLUG AND
RESIDE IN, THE ABO DESCRIBED RES NTIA OPE RTY. BANDON HOUSE SEWER
SIGNATURE r /JAL CKFILLSEPTIC TANKSOF PERMITTEE LamEP,PIT(S) ❑ CESSPOOLS ❑
) M O CASH VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK
CQ
X 1 6 5 71 OCT 21 1 0 A 5.0 ON