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HomeMy Public PortalAbout9960 HOWLAND DR_Sewer__ CE606-10-133" �. 76A642D APPLICATION ION FORR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION aUILDING � JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't o4 Building LOCALITY NEAREST ` FOR APPLICANT TO FILL INZ CROSS ST. LEGAL ell� DESCRIPTION LOT NO. �' OWNER ^ I� MAIL G BLOCK TRACT ADDRESS •T�� C - NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY �' TEL. •N O. USE'0F BUILDINGS • DISTRICT NO. GROUP MAP PROCBY /O BK PG ESSED 1 CONTRA O .J` (J Y �- ADDRESS �/ •L 0 CONNECTION DATA CITY TEL. ® STATION DEPTH STATE MANHOLE REFERENC UPPER REGISTRATION NO, E] COUNTY LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEN(/rH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L. M L'�TO P.L. } PUBLIC SEWER @ $S.00 SEPTIC TANK,SEEPAGE PIT OR P .NQ. Q. CO.IMP. NO. OB NO. O PITS AND/OR DRAINFIELD @ $10.00 V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 w CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR,NO. DATE O WORK TO HOUSE SEWER @ $3.00 V OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CE SSPOOL,DRYWELL,MANHOLE @ $5.00 HWY.OR ST.WIDENING CL d. ALTER, REPAIR OR�4Bhi'FBAfi HOUSE N SEWER OR D 64' "&TEM @ $3.00 © STATE ENCROACE Z PERMIT NO: INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2 00 AUTHORIZATION TOTAL FEE �' CONNECTION CHARGE FEE CHARGES '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 SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE ' SIGNED THIS DAY 19_ t _ OWNER OR NEW HOUSE SEWER G OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK.SEEP,PIT(S) I 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 ❑ I HEREBY CE IFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS IRED BY LOS ANGLES COON Y AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA T AT I AM THE LE O ER AND INTEND TO DISCONNECT PLUG AND RESIDE IN, E BOVE DESCRIB ESI NTI PROPERTY. ABANDON HOUSE SEWER SIGNATURE ACK ILL SEPTIC TANKS ❑ OF PERMITTEE SEEP,PITS) ❑ CESSPOOLS ❑ VALIDATIO RoaERr a. WOOD CK. M.O. SUPERVISING MECHANICAL ENGINEER CASH