HomeMy Public PortalAbout10238 GREEN ST_Sewer__ 6A642-
7
D 62 APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
G ��
JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUP T. OF BUILDINGYFOR APPLICANT TO FILL IN .
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS BK DISTRICT NO. GROUP MAP PG PROCESSED BY
CONTRACTOR' /Qx
ADDRESS V CONNECTION DATA J"-!
CITY �/ TEL. NO. STATION 3•}.��[ DEPTH l
STATE 1 fi LIC /ate MANHOLE REFERENCE
UPPER
LICENSE NO„ b �I GLASS(r WER
NO. .DEC IPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO \ Y. CURB P.L. M.L.TO P.L. lO 0-
PUBLIC
PUBLIC SEWER @ $5.00 UC/ O
P.C.NO
PITS AND/OR DRAINFIELD EEIAGE PIT OR 510.00 CO.IMP.NO. UO O• S� V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE H
WORK TO HOUSE SEWER @ $3.00 V
W
OVERFLOW SEEPAGE PIT.DRAINFIELD d
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 (n
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Z
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S CHARGES
Vel j�J[• PERMIT S 2 00
L•^ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE z/
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC 5 W , APPROVALS DA ITE I N S P ECTO R'S�NAT RE
SIGNED THIS. DAY OF460 1d/3 - 1.
OWNER ORC 1 NEW HOUSE SEWER
OWNERS AGENT J' /
CONNECT ADDITIONAL
ADDRESSLOlAk3 6. " f BUILDING OR WORK
✓ SEPTIC TANK.SEEP,PIT(S)
1 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 ❑
IHEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
SII LICENSED AS REQUILOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH M HE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND _
RESIDE IN, THE SCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑ - -
OF PERM T BACKFILL SEPTIC TANKS � -
SEEP.PIT(S) ElCESSPOOL
ALIDATION JACK:R. ALLEN
C CK , MSUPERVISING MECHANICAL ENGINEER
CK.. M. O. CASH
7 5 4 0 oEo j 1 D 7.01 0
I
I
°
S&E-683 11.55 APPLICATION FOR PERMIT 1
S&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles
JOHN A.A. LAMBIE, COUNTY ENGINEER j
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY .L'
FOR APPLICANT TO FILL IN "CROSS sr. - y'-t'
LEGAL OWNER
DESCRIPTION LOT N0. j► �,
MAIL
BLOCK TRACT ADDRESS
NO.OF BLDG'. CITY TEL. NO.
SIZE OF LOT NOW ON LOT
USE OF /
BUILDINGS DISTRICT NO. GROUP MAP
f
BK PG
CONTRACTOR +�v�
ADDRESS CONNECTION DATA
`--
CITY N0. STATION DEPTH
y J MANHOLE REFERENCE UPPER
ATE LOWER
REGISTRATION N0. ❑ COUNTY
No. DESCR TION O WOR FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR a�
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD J C.OB NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. N0.
I HOUSE SEWER CONNECTING TO ,df
PRIVATE DISPOSAL SYSTEM @ $1.00 0�"� TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
I
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PEST $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD �f
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL C3 DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY ANGELES TY AND STATE OF
CALIFORNIA OR THAT I LEGA OW ER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA 0 T BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE •
JOHN A. LAMB7, COUNTY EN ER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK, M.O. CASH
21 4 A 5.00 1R