HomeMy Public PortalAbout10104 GREEN ST_Sewer__ CE80810-63 APPLICATION FOR PERM
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
PARTMENT OF COUNTY ENGINEER
i BUILDING AND SAFETY DIVISION FADDR
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JOHN A. LAMBIE, County Engineer S
WILLIAM A. JENSEN, Sup't of Building
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NEARE
CROSS ST.
OR APPLICANT TO FILL IN
LEGALDESCRIPTION LOT NO` 7� {� � ,/A-t.b hvt A/ <`v /J–`/ '7,s A ,4 /-,'TRA T
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SIZE OF LOT NOW ON LOTCIT11' STEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCE F'D BY
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CONTRACTOR '1�• �� V..� ,?� `\ I .� 7(.,/��( .
ADDRESS Gq CONNECTION DATA
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CITY
L. NO. STATION DEPTH 6�
REGISTRATION NO. _7 ❑ STATE
l — a, MANHOLE REFERENCE / )V,
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM - "t
HOUSE SEWER CONNECTING TO �..�` Y. CURB P.L. M.L.TO P.L. / >_PUBLIC SEWER @ $5.00 Ll V P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 t)9-IMP. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.,__.
PRIVATE DISPOSAL SYSTEM @ $3.00 w
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EaSEM ENT RECORD. INSTR.NO. DATE Q
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 a
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE 7 (I-C'� CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ICON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC W DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF �• 19 "
OWNER OR4�j r NEW HOUSE SEWER
OWNERS AGENT �K CONNECT ADDITIONAL
ADDRESS /� / / BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(5)
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 ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIIDE IN, THE A;BO�FORN DESCRI M THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
REST I
OF PERMITTEE _ D ftE I )4TIA R ERTY. a ABANDON HOUSE SEWER
IA OR ASIGNATURE / -� l�F J' BACKFILL SEPTIC TANKS E] /�.
// SEEP.PIT(S)_❑ CESSPOOLSA 3�� �
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VALIDATION---,,, ROBERT A.^WOOD
CK. M.O. CASH
j/ SUPERVISING MECHANICAL ENGINEER
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