HomeMy Public PortalAbout10855 FREER ST_Sewer__ TeAesED APPLICATION FOR PERMIT .
COUNTY'oP LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION WILDING Q
JOHN A. LAMBI¢, COUNTYADDRESSomzisR ADDRESS
COLEMAN W. JENKINS. SUPT. or BUILDING
aoeALm
NKA11
RI1T
FOR APPLICANT TO FELL IN C.O. `T.
AL
DESCRIPTION LOT NO'. OWNER'
MAIL
/LOCK TRACT ADDRESS
NO. OF ■LDO/. `�J�f�]-
1
•IYI OF LOT NOW' ON LOT CI TEL. NO. �f 4
U• OF DI ICT NO OROU■ MAP
P 81 or 6� 'r, ( ■K PO
CONTRACTOR V "d 8 � � '-' '1
ADDRESS CnON DASA
CITY-EIE �f/ Y TEL NQ. RATION J1 ' ; DEPTH
�C[N/[ N c`a I'IG .4�a MANHOLE REFERENCEC/ O LOV
NO. .DESCRIPTION F WORK'' FII[ TYPE OF GONNtCTION ,L LENGTH F710 M�Q
H USE E
SEWR CONNIEgMNG TO Y. CURS M.L.TO I.L.
PUBLIC SEWER $11.00
•[TTIC TANK,SEEPAGE PI OR JOB NO. O
PITS AND/OR DRAINFI ELD $10.00 CO.IMP.NO. u
HOUSE$EWER CONNECTING T-0 T1fUHK PERMIT NO. ROAD PWRM IT HO. ce
PRIVATE DISPOSAL SYSTEM f $1.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT ""ll[$T RECORD.IMTM.NO. DATE
WORK TO HOUSE SEWER fJ.00
OVERFLOW BESPAGE PIT,DRAINFIELD
UCTN..CFASPOOL.DRYWFLLMANHOLE $8.00
ALTER.R PAIRO ABANDON HOU/ HWY. OR ST.WIDEP41HO
EH
SWER OR DI/P%A / M $7.00 [TAT[ENCROACHMENT
P[RI41T NO.
INDU/TRIAL
WAIT[APPROVAL
OPEHLmT $ 00
O CONN[CTIOH CHARGE F[[ CHARGE/
AUTHOFMTION
WNEH"S TOTAL
I HAVE AT THIS DATE A CONTRACT WIT14 THE HEREIN NAb4:; CON- RtIMSURS[MENT FEE
TRACTOR TO CONNECT THE ABOVE.DESCRIBED HX
DWELLING 7�p a
TO THE NUBLIC ■EWER. AMOVAM DATE LNSPECTOR'■SIGNATURE
SIGNED THIS
OWNER OR MEW HOUSE SKWLR
OWNERS AO[NT_ CONNECT AQDITONAL
BUILDING OR WORK
ADQRLS SEPTIC TANK.BEET.PIT(9)
1 HSREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AN /TAT[ THAT THE ABQVE IS CORRECT AND AOR[[ TO COMPLY
WITH
ALL COU NTY ORDI!{A NC[S AND STATE U1W REGULATING
PLUMBING AND SEW ERT. bESIPOOL El pRYW[LL El
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEV/[R Oft
LIC[N■[D AS REOUIR[D BY AN
ANGLES COUNTY AND STATE OF $SWAGE DIBPOML•YBT[M
CALIFORNIA �7R THAT I AM THE LE�PIRD I ND TO DISCQNNiC7 PLUG AND
REBID[ IN, TH[ AD I■ P A6AN DON HOU/[•[W ER
SIGNATURE
OF P[RMITTQ BACKFILL SEP�IC TANKS El•[ET.PIT(S) L1 CK"POOLI
`..x ATION JACK R. ALLEN
CK
'�' SUPERVISING MECHANICAL ENGINEER
. /M.O. CATH"
LALo-
g 9-9 4�3 AW1 9 1 0 D .�
DEBDB 5-55
76A 642D APPLICATION FOR PERMIT
, •',`
COUNTY OF LOS ANGET, SEWER—SI=WAGL DISPOSAL
D-2PARTb= OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIN
JOHN A. LAMBIE, County En�lneer AQDRE�B
COLEIdAN W. JENUNS,Suptt. of Balldlns LOCALITY-Tarx-' e.
N EA R EST
FOR APPLICANT TO FILL IN CROSS BT.
D ED CRIFTION LOT NO. OWH[R
MAIL
[♦LOCK TRACT A D D R EIB ,
NO. OF BLDGS. �� `
BIZ[ OF LOT NOW ON LOT CI TIL. HO ! 1 Q
USE OF DISTRICT HO. GROUP
■U ILDINOS MAP PROCESSED BY
CONTRACT �O S �Og
1=K 9 ?fir
AD ESS , CONNECTION DATA
CI Q TCL. NO. `- STATIONtC) 1^.6 D[RTN J
LICE MR LICE NRE MANHOLE REFERENCE �j
N0. CLAD' O LOWER
E
NO. DESCRIPTION OF WORK FE TYPE OF co ION LENGTH FROM
HOUSE 'EW R CONNECTINS TO Y. IRSR.L. M.L.TO PA-
PUBLIC 'LVER PIT OR IF $ 5.00
R.C_NO.
PITS ,AND/OR DRAINFIELD 0 $10.00 CO.IMP. NO. 3 JO■NO. O
HOUSE SEWER CONNECTINS TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM f $ 3.00 Ix
CONNECT A D DS. AFIFIDAVIT tAIE[[ WEBER RECORD. INSTR.NO. DATE O
-YORK TO HOUSE SE 0 $ 3.00 L
SEWER OR DISPOSAL 1 $ 5.00 06 LLVrJ
HWY.OR ST.WIDENING d
E%TN.,CE"POOL, MANHOLE 0 $ 5.00 to
STAT[CNCROACHMENT r
PERCOLATION TEST F $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERDiTf s x 00 CHARGES
CONNECTION CHARGE FEE
A=ORMATIONJ TOTAI, FEE
'I HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSENFE
MET [
TRACTOR TO CONNECT THE ABOVE DESCRIBED
TO THE PUBLIC SEWER. APPROVALS DAT[ INSPECTOR'S 81ONATURK
SIGNED THIS DAY 18_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
A 6
SEPTIC TANK.BEEF,PITS)
I HEREBY ACKNOWLEDGE THAT I HAV[ READ THIS APPLICATION A ND/OR DRAI N FIELD
AHD STAT[ THAT THE ABOVE I■ CORRECT AND AGREE TO COMPLY
WITHALL COUNTORDINANCES E RLNO
Y ODINANCS AND STATLAWS EOUATI
PLU MR ING AND SEWERS. CESSPOOL ❑ DRYW[LL ❑
I HERESY C Y IFTHAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS SQUIRED ■Y l05 ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL BYSTEM
CALIFORNIA O T}1AT I AM THELEOAL O HER O AND INT[ D TO
REBID[ IN, TH ABOVE DESCRIED RUI NTIAL ROP[RTY. DISCONNECT FLUO AND
A-DOH HOUSE SIW[R
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TkN-MISS ❑
96�.PIT(S) El CESSPOOL.{
(JALMAnON
M.O. CASH
C
LAGo 17.,9 -N24 1 0 e 5LON