HomeMy Public PortalAbout10942 FREER ST_Sewer__ c� T
CE808 3-61i
76A6421J APPLIC TION FOR PERMIT;
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
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JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Sup't of Building FOR APPLICANT TO FILL IN
LEGAL OWNER I
DESCRIPTION LOT N0.
BLOCK TRACT MAIL
7 ADDRESS
y o2 NO.OF BLDGS.
SIZE OF LOT ` ”` NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS �' ISTA
TRICT NOG� I MAP PRO ESSE BY
BK PG
CONTRACTOR +
ADDRESS r {�r CONNECTION DATA
CITY TEL.NOO.4 G' ATION DEPTH
REGISTRATION N0. L� C STATE ANHOLE REFERENCE UPPER
LOWER
No. DESCRIPTION OF W RK F ftHOUSE SEWER CONNECTING TO - to PUBLIC SEWER @ $3.00TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,PIITS AND/OR DRAENFGEDT OR @ $3.00 CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD r
EXTN..CESSPOOL.DRYWELL @ $2.00 C"
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ 100 TRUNK PERMIT N0. ROAD PERMIT N0.
O
S41111111111R,REPAIR f711 !!'HOUSE@ DO JlY-Z�. STATE ENCROACHMENT F-
PERMIT NO. U
W
INDUSTRIAL a
WASTE APPROVAL N
[=f7�7
CHARGES z
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL PEE C T REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS, � AY OF I9- NEW HOUSE SEWER
OWNER OR (/ /_ CONNECT ADDITIONAL
OWNERS AGENT /�� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [:1 DRYWELL Cl
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY IDS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE LEGAL OWNER OF T E ABOVE BACKFILL SEPTICCETANKS ❑
DESCRIBED RESIDENT PERTY.
SEE P.PIT(S) C] SSPOOLS El
SIGNATURE
OF PERMITTE
VALM.0. �� ROBSING ME A WOOD
' CK. Y.0. CASY/J SUPERVISING MECHANICAL ENGINEER