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HomeMy Public PortalAbout10129 GREEN ST_Sewer__ 0-63 76A642D APPLICATION FOR PERMIT 6A642 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Supt of Building LOCALITY 7NO. 7 NEARESTFOR APPLICANT TO FILL IN `ROSS ST. LEGAL DESCRIPTION LOT NO. OWNERMAILBLOCK %NO. OF SLID S.SIZE OF LOT NOWON LOT CITY T USE OF '77-57" �f"el/� BUILDINGS �/ eir DISTRICT NO. GROUP MAP PROCESSED BY BK PG CONTRACTOR j� � f� ADDRESS ( . ve— ©a /^ I� CONNECTION DATA STATION . CITY l L. NO. iJ /� DEPTH STATE UPPER MANHOLE REF. REGISTRATION NO. (Q c�CJ�/+ ❑ COUNTY R CE LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNE ION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 P.C.NO. d SEPTIC TANK,SEEPAGE PIT OR JOB NO. O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. U HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 w CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMEN RE RD.INSTR.NO. DATE O WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD LU EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 n. y AR'ABANDON HOUSE HWY.OR ST.WIDENING (n SEWER M @ $3.00 O� STATE ENCROACHME ' z PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT 2 00 J CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE 'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURS.j1 ENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. A PROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK.SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGAAND/OR PLUMBING AND SEWERS. ESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED LTER,REPAIR.SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I A HE LEGAL OWN OF, AND INISC NECTP UZ--A-ND RESIDE IN, THE ABOV ES RIBED RE$!DE 1 L ERTBANDON HOUSE SEWER / - _^�SIGNATURE ACKFILL SEPTIC TANKS ❑OF PERMITTEE ❑EEP.PIT(5) ❑ CESSPOOLS CK. VALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER Lr w 5 2 7 1:0� OCT 2 6 1 0 A 5.0 0-