HomeMy Public PortalAbout10232 GREEN ST_Sewer__ 1 r
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7eAe4= APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ■U ILDING pl
JOHN A. LAMBIE. COUNTY ENG1N[IER ADDRESS (�
COLEMAN W_ JENKINS. SUPT. OF BUILDING
LOCALITY
NEAREST I OF
FOR APP11CANT TO^FlU IN `"D{f ST
LEGAL
DESCRIPTION LOT NO. QV ` OW N[)t
NAIL
BLOCK TRACT ADDRR oa
NO. OF 111L.
Dow.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
eU1
CONTRACTOR
ADDRESS CONMC'nON DATA
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STATION � "1 D'-CITY NO. UPPER
//II
MLIC[N{[ NOATIE IK 7 V LI (t„i,p LI r '� MANHOLE REFERENCE 1 i 1
NO. .DESCR PE
ON OF WORK FE[ TYOF CONNECTIONL[HGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB F.
M.L.TO P.L Q d
P eLIC SEWER
$5.00
■OPTIC A K.BEEPAaK PIT OR 8 6 O
PITS AND/OR DPAINFIELD $10.00
CO.IMP.NO. JOe NO.
OUT[SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM S3.00 O
CONNECT ADDITIONAL■LDC31.OPT AFFIDAVIT RECQRO.INSTR.NO.
WORK TO HOUSE SEWER $9.00 LWJ
OVERFLOW BKKPAGE PIT,DRAINFIELD
ExTH..CESSPOOLDRYWELLMANHOLE $5.00 - N
ALTER.R A R O A ON O HWY.OR ST.WIDENING Z
f EW ER OR DISPOSAL SYSTEM $3.00 {TATE L" R ACHMEMT
PERMIT NO.
INDUOTR AL
WASTE APPROVAL
����. a CHARGE{
]�WT 2 00 CONNECTION CHARGE FR[ D _ '
AUTOi\L.iHOETZAT•Y prl
l, ION TOTAL >
1 HAVE AT THS■ DATE A CONTRACT WITH T [ HEREIN NAMED CON- REIMBURSEMENT FES
H
TRACTOR TO CONNECT THE ABOVi DESCRIBED ESISTING DWELLING �t X77 0
TO THE PUBLIC {EWER. APPROVALS DATE IN R'S SIGNATURE
SIGNED THISD Y OF 1G_
OWER OR NEW HOUR[SEWER '{
it-
OWNERS AGENT
CONNECT ADDITIONAL
WILDING OR WORK
ADDREO■
SEPTIC TANK.SEEP.PIT(S)
1 HER[eY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFI[LD
AND {TAT[ THAT THE A19QVK TO CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCE{ AND STAT[ LAW{ REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWEL� ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRE LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL-SYSTEM
W LIFORNIA OR THA HE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AN .
Q
RLI D[ IN, THE RIED RESIItDENTIAL PROPERTY. ABANDON HOUSE SEW# .
U
SIGNATRE - BACKF ILL S[FTlC TANKS ❑
OF F"M SEEP.PITS) (J CESSPOOLS
VAI.IDATI JACK R. ALLEN
CK. M.O. CATH
SUPERVISINGI'
M4HANICAL ENGINEER
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