HomeMy Public PortalAbout10147 GREEN ST_Sewer__ ,°-63
76A642D APPLICATION FOR PERMIT
6A64
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, Sup't of Building
LOCALITY G /
NEAREST
FQ_R APPLICANT TO FILL IN CR°s5 5T.
LEGAL
DES PT ON.� aT N WNER
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MAIL �
BLO I - TRACT - ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF �� DISTRICT NO. GROUP MAP PROCESSED BY
BUILDNGS IBK PG
CONTRACTO � 1
ADDRESS CONNECTION DATA
JA
TA
STATION DEPTH
CITYf/&) h �I/_—TEL. NO4 � _
t
/ 3P STATE MANHOLE REFERENCE E
UPPR
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO-P.L. }
PUBLIC SEWER @ $5.00 P C NO.' 0-
SEPTIC
SEPTIC TANK,SEEPAGE PIT OR JOB X0. O
PITS ANDOR DRAINFIELD @ $10.00 CO.IMP. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. R D PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT F�ECORD. STIR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 ~
U
OVERFLOW SEEPAGE PIT,DRAINFIELD 1J.1
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 h
ABANDON HOUSE HWY.OR ST.WIDENING
de SEWER- SEM @ S3.00 STATE ENCROACHM5W
PERMIT NO.
INDUSTRIAL
WASTE APPR AL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. 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 REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ 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 THE LEGAL OWNER OF, AND INTEND TO DlcrO ur�c.r T.=.R41JI--ND
RESIDE IN, THE ABOV E CRIBEDRESID �PERTY. ABANDON HOUSE SEW ER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT TEECESSPOOLS
�- ❑
V SEEP,PIT(S) ❑
�J ALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAUO5 2 7 3zi; OCT 26 1 0 A 5.00- `'