HomeMy Public PortalAbout10203 GREEN ST_Sewer__ � 1
4650 IRSERTS
CE6066-
76A642D 60 APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES1
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER qq
BUILDING AND SAFETY DIVISION ADDRESSG
JOHN A. LAMBIE, County Engin eer
WILLIAM A. JENSEN, Sup't of Building LOCALITY 7',n
NEAREST .�
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL XP _ ' &-L' / OWNER 9J, R'` 4�'C'_ e a
DESCRIPTION LOT N0. V
BLOCK TRACT / MAIL -
K ADDRESSNO.OF BLDG
SIZE OF LOT / NOW ON LOTS CITY /CjIft a OPi7V TEL. NO.
BUILDINGS �' lI"-ok DISTRICT N0. GROUP I OF MAP SSED BY
BK PG I
CONTRACTOR -I,) y �.�. '
ADDRESS - CONNECTION DATA _.e(
.- �✓t Ly
CITY° � �. "�1'EL.N0. _
STATION DEPTH
STATE MANHOLE RE RENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $1.00 TYPE OF CONNEC ON LEN H FROM
PITS AND/OR SEPTIC TANK,
RAINFGELDIT OR @ $ 00 Y. CURB P.L. M. .TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $ .00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $ .00 CO. IMP.NO. NB NO. 7+
CONNECT ADDITIONAL BLDG.OR p'
,WORK TO HOUSE SEWER @ $1100 TRUNK PERMIT NO. ROA PERMIT NO. U
ABANDON HOUSE STATE ENCROACHMENT
SEik�1�R ojSPOSAL SYSTEM @ $ .00 PERMIT NO. !O!
INDUSTRIAL `j
WASTE APPROVAL W
CHARGES
OWNERS PERMIT $ p 00 CONNECTION C ARGE FEE
AUTHORIZATION I TOTAL FEE 1 5-
REIMBURS ENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT WITH THE IJNGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT
HOUSE D
CALIFORNIA OR THAT 1 AM THE LEGAL OWN R OF HE ABOVE
DESCRIBED RESIDENT ROP Y p BACKFILL SEPTIC TANKS ❑
SIGNATURE i
SEEP.PIT(S) El CESSPOOLS
OF PERMIT - I' e
OF /-VALIDATION ROBERT A. WOOD
R.o, CASH SUPERVISING MECHANICAL ENGINEER
L"3 3 3 2"4Ql Am22 1 0 D 5.00— V