HomeMy Public PortalAbout10938 FREER ST_Sewer__ C"053-e4 ., APPLICATION FOR PERMIT
7eAe4:D
covxTY of I.os ANGELES SEWER—SEWAGE DISPOSAL
DEPARTNIMT OF COUNTY ENGINEER
BUI�LffiDD��IN�AG.. �A■NDD SAFETtY� gDIVVIISION °�oonw
WTLLIAx A. I�&, evy'4 0!nrwml
LOCAL"
NEAREST
FOR APPLICANT XO FILL IN CROWS �•
LEGAL
DESCRI N LOT NO. OWNER
MAIL
FLOCK TRACT ADDRESS
O. 16 F 9LDQ S.
SIZE OF LOT NOW .!f LOT CITY TEL NO.
USE OF DISTRICT mo.1 GROU rR
MAP OCL■SLD BY
BUILDINGS UK
CONTRACTOR • / 0 4:� 't:: - L? 4
ADDRESS nr C NNECTION DATA
ION DEPTH
cITY
STAT[ UPPER
MANHOLE-.C[
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE of LENGTH ow
HOUSE SEWER CONNECTING TO M.L.TO
PUBLIC SEWER S5.60 P.C-NO.
"FIVIC TANK, PAG[P JO■HO.
'ITS AND/OR DRAINFI[LD •10.00 CO.IMP. NO.
HOUSE SEWER COMP49CTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRI VAT[DIGP04AL SYSTEM f 59.00
CONN[ ADDITIONAL al-DO.OR AFFIDAVIT RECORD.11491R.NO. DAPI
WORK TO HOUSE SEWER S2.00 }+
OVERFLOW SEEPAGE PIT,DRAINFIELD
[I(TN.,CESS OL,DRYW[L L,MANHOL[ •8.00
AL ,R A R A OHS HWY.OR ST.WIDENING
SEWER DISPOS M 9.00 WT TE ENCROACHMENT 2
PERMIT NO.
INDUSTRIAL ti
WAST[APPROVAL
CHARGES
OWNER'S PEBMT s
AUTHORTLATION TOTAL FEF CONNECTION CHARD[FEE
'1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON- REIMBURAEMENT FEE
TRACTOR TO CONNECT THE A■OV[ D[SCAISED 77 �T a
TO THE PUBLIC SEWER. APPROVALS DATL INSPECTOR'S SIGNATURE
E
SIQNED THIS to_
OWNER OR NEW HOUR[S[W[R
OWNERS AO[NT CONNECT ADDITIONAL
■U I LDI NO OR WORK
ADDRESS SEPTIC TANK,SKIT,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI INFIELD
AND STAT[ THAT THE ABOVE In CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWN REGULATING ✓
PLUM SING AND ■EWERS. C[BSFOOL ❑ DRYWELL ❑
I HERESY CERTIFY THAT I AM PROPERLY R[OI [RED ANDIOR ALTER,REPAIR,SEWER OR ,,aa
LICENSED AS REO BY LOS ANLL COU AND STATE OF 9EWAOR DISPOSAL SYSTEM
CALIFORNIA OR AT AM TH[ LEGA N[ OF AND INTEND TO DISCONNECT PLUG AND
REDID[ IN, A [ DESCRI■[D D A OP[RTY. ASANDON HOUSE SEW ER
SIGNATURE � SAC KFILL C TANKS ❑
OF FERMI ■[EP,PIT(■) CESSPOOLS
M.Q,
VAL � ROBERT A. WOOD
cK. M.p. C( CA,SF{ BUrERV181N0 MECHANICAL HN61N6ER
[AC,08564�8 JN 61. 1 D 25.00 1_
CE806 x4 %APLIIATION eRFP
7x86420D '• u
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUELDING AND SAFETY DIVISION
Oi xU
VLM C I8ADJ
S
P ,
LOCALITY G
NEARE.T
LIE GA L FOR APPLICANT TO FILL IN CRD§/ eT.
D[/C RIPTION LOT NO. OWNER G T
/ MAIL
BLOCK TRACT f L ADDR[/f
NO. OF nLp6z.
SIZE OF LOT NOW ON LOT CITY TEL NO.
BE OF DISTRICT NO. GROU .K MAP PROCLSfED■Y
BUILDING■ _
CONTRACTOR C . ��
ADDRw CONNECTION DATA
CITY TEL Ly ION D[r'TM /
UP
RAS MANHOLE REFERENCE
RZOISTRATION NO. COUNTY
No DESCRIPTION OP WORK of C n LE WITHoY
E
HOUSE SEWER CONNECTING TO Y. M.L TO
PUBLIC■EWER 0 8..00P.C.NO. }
[FfIC A ,/ OR CO.IMP.NO. JOB NO. D.
PITS AND/OR DPAINFIELD /10.00 O
OU/E/ ER CONNECTING O TRUNK PERMIT NO. ROAD PSRMIT NO. U
PRIVATE DISPOSAL SYSTEM •9.00
CONNECT ADD L. BFFIDAVIT SAfY[� Lumm" RECORD.IN/TR.NO. DATE
WORK TO HOU.[■EWER $7.00 FO
OV FLOW/[[PAGE PIT.DRAINFI[LD
EXTN..CESSPOOLDRYWELLMANHOL[ $/.00
H WY.OR/T.WIDENING N�
N HOUSE
■EWER OR DINPOSAL/IR OR Y/TEM03.09 STAT[SNCROACHM9Wr =i
PERMIT NO. L_
INDUSTRIAL
WASTS"PROVAL
OWNERS PERMIT t E 00
CONNECTION CHARD[FEE CHARGE/
AOTHOFMTION TOTAL FEE
'I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMM3 CON. REIM■URSEMSNT FEE
TRACTOR TO CONNECT THE ^WOVE D[SCRI■ID �}�� �T�
TO THE PUBLIC SEWER. APPROVALS DAT[ INSPECTOR'/814TUR[
SIGNED THIO DAY F l0_
OWNER OR NEW HOUSE SEWER
OWNER/Ati[NT CONN19CT ADDITIONAL
BUILDING OR WORK
ADDRESS
alPTIC1 HEREBGA
Y ACKNOWLEDGE THAT 1 HV[ RLAND/O
AD THIS PPLICATION TANK,■[IT,PIT(/)
AND /TATE THAT THE A.OYI 1■ CORRECT AND ACRE[ O COMPLY AHD/OR DRAINFI[LD
WITH ALL COUNTY ORDINANCES AND -STATE LAWS EGULATING
PLUMING AND SEWERS. CEDSPOOL ❑ DRYWSLL ❑
1HEREBY CERTIFY 1 AY PROP[ Y RE01 ED AND/QR ALTER,REPAIR,SEWER OR
LIC[NS(<D AS REO LO/ ANGL O ND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR I THE LEGAL E F, ND INTEND TO DISCONNECT PLUG AND
READ[ IN. THE ESCRIBID L P DON PLUG AND
SIGNATURE ) SACKPILL S[PTEC TANKS ❑
OF PERMITTEE Sur.P".) LJ CiS1POOIJ
VAlMATIO ROBERT A. WOOD
SUPERVISING MECHANICAL 11NO1NEER
CK. Y.O. CASH
LAC08 5 6 J" 6 1 0 D 7.00N !Z