HomeMy Public PortalAbout9966 HOWLAND DR_Sewer__ 6A64 APPLOCA TION FO f'C ��RMIT
C E808 DD 4-
COUNTY OF LOS ANGELES SEWER-SEVVAGE"DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
�. LOCALITY
NEAREST
FOR APPLICANT TO FI INCROSS 5T.
LEGAL
DESCRIPTION LOT NO. OWNER
r. MAIL
BLOCK TRACT T ADDRESS
NO. OF BLDGS. - p�-
SIZE OF LOT NOW ON LOT CITY - TEL. NO.
USE OF
BUILDIDISTRICT NO. GROUP MAP
NGS 7 DISOPOCIESSEED BY
�jTRI j ,N B PG
CONTRACTOR
ADDRESS gCONNECTION DATA
CITY EL. NATION / _/ /, DEPTH
TATE El
ER
'19MANHOLE REFERENCE
REGISTRATION NO. El COUNTY J
N O.. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ 55.00
SEPTIC TANK,SEEPAGE PIT OR P.G.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. Z& 7 JOB NO. //�� O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N�!Q�j V
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD {JJ
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ S5.00
ALTER,REPAIR OR ABANDON HOUSE HWY. T ID N
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE EN ROACH L
PERM
IN
WASTE APPROVAL
OWNERS PERMIT S 2 Oo CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E) TING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'SI SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER II-Zx�-
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANG E5 COU TY AND STATE OF '[ SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR I AM THE OWNER F. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, T A VE DESCRIB R SI NTI PROPERTY. � ABANDON HOUSE SEWER
• SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(5) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAW 6 2 3 5.a NOV 27 1 0 D 7.00.-