HomeMy Public PortalAbout5902 IVAR AVE_Sewer__ C.E808 5-65 APPLICATION FOR PERMIT
76A 642D COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISP SAL
BUILDING AND SAFETY DIVISION BUILDING -c
JOAN A. LANIBIE, County Engineer ADDRESS C
COLEJIAN W. JENKINS,Sup't. of Building
LO CALiTY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL `
�
DESCRIPTION LOT N15 / e OWNER
MAIL
BLOCK TRACT r5 ADDRESS
OF BLDGS.
SIZE OF LOT'5–aaO OW ON LOT - CITY TEL. -NO.
' USE OF tl
-D ISTRICT NO. GRO
BUILDINGS C UP MAP PROCESSED BY
BK PG
1
CONTRACTOR )
ADDRESS a '! CONNECTION DATA
CITY" ry - EL. N H• STATION / �/ y.s DEPTH
LICENSE - L CENSE v�'���/ V'
NO. CLASS MANHOLE REFERE NCE
NO. ESC IPTION OF WORK FEE TYPE OF CO ION LENGTH FROM—
LOWE
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TO P.L.
PUBLIC SEWER C' $ 5.00 V®
SEPTIC TANK., SEEPAGE PIT OR ^�® P.C.NO. a
PITS AND/OR DRAINFIELD C' $(0,00 CO.IMP.NO. a JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVEN Ens Ex ExT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER C' .$ 3.00 O
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM L^-. $ 3.00 �
HWY. OR ST.WIDENING a
EXTN.,CESSPOOL, MANHOLE C $ 5.00 h
STATE ENCROACHMENT
I PERCOLATION TEST @ $ 5.00 PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OWNERCHARGESS PERMIT t r o0
AUTHORIZATION TOTAL FEE 16 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE J
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW Eg APPROVALS DATE INSP CT 'S SIGNATURE
SIGNED THIS f`2 DAY O,F 'y 19
OWNER OR /� /7 r NEW HOUSE SEWER �{ }�+ '•,
OWNERS AGENT �•
�y �jy CONNECT ADDITIONAL
AODRESSw / 9Z
BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PLICATIO AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR a ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED ESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
F
SIGNATURE
OF PERM ITTEE BACKFILL SEPTIC TANKS [I /r
SEEP.PITS) ❑ CESSPOOLS j❑ f
VALIDATION
CK. M.O. CASH
=' =J 4 7 0 5-_� SLI 1 1 0' D 7,0 0.