HomeMy Public PortalAbout5926 IVAR AVE_Sewer__ CE808 UO-63
APPLICATION FOR PERMIT
76A642D LI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS (fo
WILLIAM A. JENSEN, Sup't of Building
- LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSB BT.
LEGAL ^
DESCRIPTION LOT NO. Lf OWNER
/. MAIL
BLOCK TRACT � ADDRESS 1,
NO, OF BLDGS. y{
SIZE OF'LOT NOW ON LOT CITY �'� TEL. NO, rjf/®
USE OF DISTRICT NO.:..GROUP MAP PROCESSED BY
BK PG /1
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
F-1STATE UPPER
MANHOLE REFERE
REGISTRATION NO. El COUNTY
NCE LOWER
[jHOU
DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
USE SEWER CONNECTING TO Y. CURB P.L. O P.L. }
BLIC SEWER @ $5.00
PTIC TANK,SEEPAGE PIT OR P.C.NO.
S ANDOR DRAINFIELD @ $10.00 CO.IMP. NO JOB NO. O
V
SE SEWER CONNECTING TO U ROAD PERMIT NO.
IVATE DISPOSAL SYSTEM @ $3.00 K
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEII EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT, LLI DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANH O LE @ $5.00 a
a-
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z Oo CHARGES
AUTHORIZATION I TOTAL FEE t CONNECTION RGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REI RSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT IHAVE 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 ANDVOR 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 AB Ef ED RESID TJTIAL PFPP.ERTY. ABANDON HOUSE SEWER
SIGNATURE EE BACKFILL SEPTIC TANKS ElOF PERMITT
� SEEP,PITS) ElCESSPOOLS E]
VALIDATION ROBERT A. WOOD
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
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