HomeMy Public PortalAbout10847 FREER ST_Sewer__ 76A 642D - CE806 - 9/73 APPLICATIO FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 102';V;7
ADDRESS }
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN GROSS ST.
LEGAL J / �0��
DESCRIPTION LOT NO oti 3 y OWNER jG /{ v C �
MAIL
BLOCK TRACT D IC/G ADDRESS D �LO 4/yy
NO OF BLOCS
.SIZE OF LOT NOW ON LOT CITY AA>cATEL. NO.
USE OF DISTRICT NO GROUP MAP p CESSED•BY
BUILDINGS �f �) /J"��a /R_ 8K L//L PS
GONTRACTOR ?UR R bC� �4eWe `
ADDRESS �J CO/NNECTIO DATA
CITY STATE '�T7EL. NO. / / vh '� STATION /i•f I DEPTH q
LICENSE NO, /-z or GLALIC SS C �'• .Z MANHOLE REFERENCE /" �-J )GJ�C� LUPPER
NO. DESCRIPTION OF WORK FEE TYPE OF GON VECTION > `J v LENGTHI FROMG
HOUSE SEWER CONNECTING TO16)71 M.L.TO P L.
PUBLIC SEWER 0 $7.00 J-' P.0 NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ sl0 00 CO IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S300
Co ECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
WORK TO HOUSE SEWER ® $300 p}„
OVERFLOW SEEPAGE PIT,DRAINFIELD CD
EXTN.CESSPOOL DRYWELL, $500 V
WIDENING
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST. �
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT CD
MANHOLE $7.00 PERMIT NO. W
INDUSTRIAL �•.
WASTE APPROVAL N
Z
OWNERTf S PERMs
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
IHAVE 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
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF CRNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS ❑
OF PE4RMTT7EE SEEP.PITS) ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH
999r"-- cT2810u 15.00