HomeMy Public PortalAbout10038 GREEN ST_Sewer__ C E606 10-63
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD
JOHN A. LAMBIE, County Engineer ADDR
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FIIAL IN `ROSS ST. -
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N �G7C
USE OF DISTRICT 7GT MAP PROCESSED BY
BUILDINGS BK PG
-L7T A
CONTRACTOR i" 4. G
ADDRE CONNECTION DATA
/ �Y STATION -11 . DEPTH
CITY TEL. NO. v
77
STATE MANHOLE REFERENCE / �
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION F WORK FEE TYPE OF CONNECTION LENGTH FR
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER @ $5.00 . P.C.NO
O
SEPTIC TANK.SEEPAGE PIT OR L IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ 810.00 IL)
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 w
CONNECT ADDITIONAL BLDG.4IIIIIIIIIIIIr AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR.NO. DATE O
#FO HOUSE SEWER @ S3.00 U
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN.,C ESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING (�
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 Oo
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 10
REIMBURSEMENT FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _ APPROVALS _
TO THE PUBLIC SEWER. DATE INSPECT R' SIGNATURE
SIGNED THIS DAY OF .%J��,, 19_ T11
OWNER OR '^'^ � `7Ry� NEW HOUSE SEWER ''�.•
OWNERS AGENT�._�_ter_ CONNECTADDITIONAL /
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [I DRYWELL ❑
I HEREBY 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB VE DESCRIBED RESIDENTIAL ROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ el
- '� ,�'�p+
OF PERMITTE SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION R BERT A. WOOD
( CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
A 1 0 6 2 A¢R 7 1 U D 1 0.00- c