HomeMy Public PortalAbout8625 HALDEMAN ST_Sewer__ '44650'INSERTS
660
7eA642D APPLICATION" FOR PERMIT - '
sazn COUNTY OF LOS-ANGELES SEWER—SEWAGaE DISPOSAL
DEPARTMENT OF COUNTY'ENGWEER BUILDING
BUILDING'AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County-En ineer
WILLIAM A. JENSEN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN caoss ST.
LEGAL '-
DESCRIPTION - LOT N0. f7 OWNER. -
•
BLOCK TRAC - MAILADDRESS
NO OF BLDGS. _ - '
SIZE OF LOT NOW N LOT CITY TEL �NO.
USE DISTRICT NO. TEL
MAP ESS BY
BUILDINGS - BK s'PG _ -
CONTR 0 W
ADDRESS CONNECTIO DATA
CITY s .NO .p ?-PO" STATION• DEPTH
[] STATE MANHOLE REFERENCE UPPER-
REGISTRATION NO T771LJ COUNTY G
NO DESCRIPTION OF WORK FEE -
PHOUSE UBSEWE CONNECTING TO
S CSEWER_ @ $3 00c _c�
TYPE OF CONNECTIO LENGTH FROM.�
SEPTIC TANK,SEEPAGE PIT OR Y: CURB P.L. M.L.
TO P.L.
s
PITS AND/OR DRAINFIELD - @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD '
EXTN CESSPOOL DRYWELL @ $2 00 -
HOUSE SEWER CONNECTING TO P.C.N0. 5� '
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @ $1 00 V
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 'STATE ENCROACHMENT
•PERMIT NO p
' 'INDUSTRIAL H
WASTE APPROVAL W `
CHARGES rrAA
OWNER'S 'PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
NAMED CN-
TRACTOR TO CIONNECT"THE ABOVE ES RIBED EXDATE A CONTRACT WITH THERETNNG DWELLING APPROVALS r DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. ss
SIGNED THIS F 1J— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL - -
OWNERS AGENT .BUILDING OR WORK - - -
SEPTIC TANK,SEEP:PITS)
ADDRESS AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ `
WITH ALL COUNTY +ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
•PLUMBING AND SE RS., SEWAGE DISPOSAL SYSTEM y
1 HEREBY IFY THAT I AM OPIERLY REGI TERED AND/OR DISCONNECT PLUG AND '
LICENSED AS OUIRED BY LOS GEL S COUNT AND STATE OF ABANDON HOUSE SEWER
CAL^IFORNI THAT I AM THE L OWN OF THE ABOVE BACKFILL SEPTIC TANKS ❑ _ -
DESCRIBE ENTIAL PROPERTY. SEEP.PIT.(S CESSPOOLS ❑
SIGNAT E (� -OF P MITTE •
VALIDATION ROBERT A.,WOOD
IL
CM.0. CASH SUPERVISING MECHANICAL ENGINEER
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