HomeMy Public PortalAbout10210 GREEN ST_Sewer__ l 77—
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CEDO4 e-°`
70Ae4:o APPLICATION FOR PERMIT
F LOS
ANGELESSEWER-SEWAGE DISPOS
DEP�OF CQUWW ENG2=
BUELDING AND SAFETY DIVISION BuitdhLg
■UILDIN /1 O
JL _-mow �'of ADDRW f/
l.f)�, 6�� LO CAL 17Y
NEAREST
FOR APPLICANT TO FILL IN `Ross `r•
DESCRIPTION LOT NO 2 OWNER
MAIL
Wr
BLOCK TRA ADDRW
NO. cfF TiLDas.
SIZE OF LOT NOW ON LOT CITY TIL. NO.
USK OF DISTRICT NO, GROUP MAF rR BY
BUILDINGS {/,D �K^ /pr��0
CONTRACTOR / A
PIP of !N
ADDRE„ 57v,f CONNECTION DATA
CITY L t TEL NO. �!7 STATION` < q[PTFIIr
�] AT[ `l U R
REGISTRATION NO. lorn v COUNTY MANHOLE R[FiRINCt
04
No. DESCRIPTIONwOF WORK FEE P[6r,CONNECTION LENGFRO
E
HOUSE SWER CONNECTING TO Y. CUR■ P,L TL
M.L. O P.
P SLIC S[WiR 0 13.00 k. P,C.NO. }
ICA P OR CO.IMP.NO. �� D_
PITS AND/OR DRAINFIELD 0 [10.00 O
No UE
SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (J
PRIVATE DISPOSAL SYSTEM 0 57.00
CO ADDITIONAL■ G. AFFIDAVIT SAft[I EMIRIR RECORD.INS".NO. DATE D1
WORK TO HOUSE SEWER 0 $2.00 O,
OVERFLOW 01"AGK PIT,DRAINFItLD
E)(TH.,CXS POOL,DRYWELLMANHOLK 0 $5.00
AL R.REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING 13-
a R
_aEW[R OR bISFOSAL SYSTEM 43.00 STATE ENCROACHM Z
PERMIT No.
INDUSTRIAL
WASTE APPROVAL
O Y11Y i.✓Q�A
PEEWT J 2 00 CHARGES
77 AUTHOPMTION TOTAL FEE jf^JJ CONNECTION CHARGE Fu
'1 HAVE AT THIS DATE A CON-TRACT WITH THE H"KIN MtD CON- REIMBURSEMENT"m
TRACTOR TO CONNECT THE A50YK D[SCRIBSD []LISTING DWELLING }�p� �I
TO THE PUBLIC SEWER. AMOVAM DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF' 10_
OWMER OR NEW HOUSE SEWR
OWNERS AGENT CONNECT ADDIT I OVAL
■U ILDING OR WORK
ADDRESS ■[DTIC TANK.SEEP.PIT(S)
I HERESY ACKNOT-
His THAT I HAV[ READ TIS APPLICATION AND/OR D#AI N F I t LD
AND STATE THAT THE A■OVt IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. - CESSPOOL ❑ DRYWELL ❑
1HRI■Y CERTIFY THA AM "OPIXLY REGISTERm AND/OR ALTER.REPAIR,SEWEROR
LICENSED AS REQUIRED OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT HE'LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND,
Rte,Dt IN, THE A RIBED,l1ESIDENTI L PROPERTY. ABANDON HOUSE S[WR
■IGNATURt SACKFILL SErBC TANKS ❑
OF PRMITTt.[ RQ,PIT(S) LJ. CWPOOLJ
VALIDATZO ROBHRT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CATH
LAC0472VS MU168 0 D 233.40
4 7 2 2S MAY16 1 0 D 1 0.00~
„"X�a”11.05 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE.D 1 S POSA L
D"-ewwnt a co—ty Ealftm«r
County of Lo. Ate» FA�DD
DING
JOHN A.LAMBIE, CouNrY ENGINEER MCABBATF D.GRIFFIN, SUPT OF BUILDING LIrtFOB. APPLICANT TO FILL IN aT
LEGAL
D[fCRIPTIOX LOT N0. E 77 o F
BLOCK +®�0 6-d�' �7- d�P6 MAIL .�
ADDRESS
NO.OF BLDGS. CITY TEL. N0.
SIZE Of LOT NO■ON LOT
SE.OF DISTRICT NO. GROUP KAP
BK re
CONTRACTOR
F cOMU=ON DATA
ADDRESS
STATI DEPTH
CITY TEL MO. MANHOLE RIFER UPP�1
LOWER
RE619TFATION NO, COUNTY
X DESCRIPTION OF WORK FEE
TYPE
HOUSE SEWER CONNECTING TO OF CONNECTION GT
NFROM
Y. CURB P.L TOO P.L
PUBLIC SEWER 3.60
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® S 5.00
OVERFLO BE AGE PIT,D>r4*9L&i!- P. C. NO.
2.00 CO. IMP.N0. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® f 1.00 TRUNK PERMIT ROAD PERMIT MO
CONNECT ADDITIONAL BLDG.OR STATE.EX CRO HYEN7
WORK TO HOUSE SEWER ® S 1.00 PERMIT XO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTR
SEVER OR DISPOSAL SYSTEM @ 1.00 WASTE AI ROVAL
CHARGES
FE
NFCTION CHARGE E
OWNE'S 1 00
IMBURSEMENT FEE
AUTHORIZATION TOTAL FEE a0
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAY X- APPROVALS. DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. XEW HOUSE SEWER
SIGNED THIS IIAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT StPTIC TANK,SEEP,PIT(9) i
ADDRESS AMD/OR DPAINFIELP
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,RE AIR,SEWER OR
L
AND SEWERS. - SEWAGE DISPOSALSYSTE CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
S REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSES OR THAT I AY THE LEGAL OWNER OF THE ABOVE
RESIDENT PROPERTY. BACKFILL SEPTIC TANKS❑SEEP.PIT(S) ❑ CESSPOOLS❑
TTEE
JOHN A. LAMBIE, COuNYY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLJBG. INBPMCTOR
a. o.o. c"11
_ 0 8 1 9 0 ? JUL 1? 4 3.0 0. tn