HomeMy Public PortalAbout10105 GREEN ST_Sewer__ r
CE306 5-65
76A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DIS, OSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMBIE, County Engineer ADDRESS
COLEMAN W. JENKINS,Sup't. of Building
LOCALITY
NEAREST `
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL l
DESCRIPTION LOT NO. s OWNER
MAIL
BLOCK TRACTADDRESS
/ ' NO. OF BL GS.
SIZE OF LOT SDy /`Q NOW ON LOT CITY TEL. NO ido
USE OF 11 SE-
BUILDINGS �bI DISTRICT NO. GROU MAP ROCESSED BY
BK /PG
CONTRACTOR , �T�.�
ADDRESS CONNECTION DATA
DEPTH
CITY / TEL. NO STATION �
LICEN LICENSE ..y .�
N0. CLASS MANHOLE REFERENCE C/'S
LOWER
NO. 1 ZESCRIPTTON OF WORK FEE TYPE OF CONNECTIONLENG H FROM
HOUSE SEWER CONNECTING TO Q� Y. CURB P.L. M.L. O P.L.
PUBLIC SEWER C $ 5.00 (J'v P.C.NO.
PTA ANK, SEEPAGE PIT 09
GIMP.NO. JOB NO. LL
PITS ND/OR DRAINF IELD C $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (�
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUE SEWER C $ 3.00
R R ABANDON HOUSE OR
SEWER OR DISPOSAL SYSTEM C $ 3.00 C�
HWY.OR ST.WIDENING C
EXT N.,CESSPOOL, MANHOLE g $ 5.00 STATE ENCROACHMENT y
I PERCOLATION TEST C $ 5.00 PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN ZMEID CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW R. APPROVALS DATE INSP CTOR'S IGNATURE
SIGNED THIS DAY OF 194BOWNER OR -71,'
OWNERS AGEN J NEW HOUSE SEWER
CONNECT ADDITIONAL
ADDRESS e. BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAT NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ElPLUMBING AND SEWERS. CESSPOOL C3DRYWELL
I HEREBY CERTIFY THAT IAM 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 ABOVE DESCRIBE RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE /
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP,PITS) ❑ CESSPO
A(CALIDATION
M.O. CASH
LA,04 2 0 mAy 3 1 D 7.00