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HomeMy Public PortalAbout10118 1/2 GREEN ST_Sewer__ s 1G_62 7GA646A842D APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST G JOHN A. LAMBIE, County Engineer 19 (Ireem Street WILLIAM A. JENSEN, Supt of Building `]em le City. Calif Y FOR APPLICANT TO FILL IN T. LEGAL DESCRIPTION LOT NO. OWNER Donna Iillett MAIL BLOCK TRACT 1 ADDRESS 101GreenStreet NO. OF BLDGS. l}7 GI �_` O2 SIZE OF LOT NOW ON LOT CITY jel7i le C]��j TEL. NO. USE OF BUILDINGS /'I DISTRICT NO. GROUP MAP �jR OC ES BY BK PG /� CONTRACTOR (// Owler L ADDRESS CONNECTION DATA CITY TEL. NO. STATION DEPTH ' ❑ STATE -UPPER REGISTRATION NO. ❑ COUNTY HOLE REFERENCE LOWER NO. DESCRIPTION OF WORK FEE TYPE ONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. C P.L. MA,.TO P.L. O PUBLIC SEWER @ $5.00 p 4,N0 V CO. . SEPTIC TANK,SEEPAGE PIT OR IMPNOjCSB NO. PITS AND/OR DRAINFIELD @ $10.00 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 � ab - _ CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EAs7 RECORD. INSTR.Nb, DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD y EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 HWY.OR ST.WIDEN rLLLi ALTER.REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL STS. EM @ $3.00 STATE ENCROACHNT PERMIT NO. Ir INDUSTRIAL WASTE APPROV L CHARGES OWNERS PERMIT $ ,2 Oo AUTHORIZATION TOTAL FEE �' CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLISEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF -19- OWNER 9OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL. 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 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSEDAS 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, T VE DESCRI RE N PR ABANDON HOUSE SEWER ERT SOP IGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMIT TE SEEP.PITS) ❑ CESSPOOLS ❑ 0CK. ALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER � L:it, 9 9 2 8,12 SEP 10 1 © D 5.00-