HomeMy Public PortalAbout5650 HELEO AVE_Sewer__ D
CE005-e-sa APPLICATION FOR PERMIT
aeoe- COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER' -
BUHMIAG AND SAFETY DIVISION BDILDING 5650. Heleo Ave.
JOHN A. LAMBIB. County Engineer ADDRESS.
CASSATT D. GRIFFIN. Supt of Building LOCALITY �emP�-e l'ris -
NEAREST roa Way -
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL e OWNER O "Itzgerald
DESCRIPTION LOT NO.
BLOCK TRACT 25202 MAIL
ADDRESS 21121 Mesa Rica Road
NO. OF SLUGS. Uovina. ED 2-792-5
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF .
BUILDINGS DISTRICT N0. GROUP MAPB CESSED BY
T MT� .L BK PG /
CONTRACTOR Le M. CQJ1S'CrUQ'tl OIl C . i/J
ADDRESS 5136-No. Blee$er- •.CONNECTION DATA
CITY win ar TEL. NO. ED 8-3024 STATION DEPTH
STATE MANHOLE REFERENCE - .UPPER
REGISTRATION N0. B COUNTY S�
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER (� §9.00 �� ,TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK, SEEPAGE PIT OR Y. CURB .L. M.L.TO P.L. -7
PITS AND/OR DRAINFIELD fg $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
E%TN..CESSP00 L.DRYWELL,MANHOLE � $2.00
HOUSE SEWER CONNECTING TO N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0:
WORK TO HOUSE SEWER .0 $1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE.APPROVAL
CHARGES
OWNERS PST $ 2 �0�0/� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Il_+ REIMBURSEMENT FEE
1 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. rr
SIGNED THIS-DAY OF Jy_ NEw HOUSE SEWER
OWNER OR NEW C O NNECT ADDITIONAL
OWNER$AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT IS)
ADDRESS ANDIOR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANDAK DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA T I AM TH LE AL OWHER OF THE ABOVE
DESCRIBED RESIDENTI PRO BACKFPIT S)SEPTIC
TANKS[D ❑
SIGNATURE
OF PERMITTE
®.! VALIDATION ROBERTA.WOOD_
.SUPERVISING MECHANICAL ENGINEER
UA099242 i"YW 181 _0 -A 5.00 � , .: