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HomeMy Public PortalAbout5927-29 IVAR AVE_Sewer__ CEBOB 3.62 - 76A642D APPLICATOON FOR PERMOT V - COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL LJ DEPARTMENT OF COUNTY ENGINEER -- BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY /� �� -. 7AL NEAREST OR APPLICANT TO FILL IN CROSS 5T.-.. ` Y\DESLOT NO. FOWNERMAILBLOTRACT L �` ADDRESS ' �� _ s 'y / NO. OF BLDG S. {I, SIZE OF LOT ©x�fr NOW ON LOT CITY ±?� n /1)e/ V TEL. NO.�_ ` �y USEOF .. .. ,,... ::�. J_ BUILDINGS" '� (//> - ---• - DISTRICT N GROUP - ..) MAP PROCESSED BY SK PG CONTRACTOR .' € ADDRESSs y ( -/ !-,Y'F_ CONNECTION DATA CITY 11 EL. NO. '.!7 STATION DEPTH STATE LIC ' MANHOLE REFERENCE F UPPER LICENSE NO.. GLASS .- //1•% LOWER NO. .DESCRIPTION OF WORK FEE TYPE OF C VECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. d PUBLIC SEWER @ $5.00 - - O • P.C.NO. SEPTIC TANK.SEEPAGE PIT OR JOB NO. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. V HOUSE SEWER CONNECTING TO O TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ S3.00 CONNECT ADDITIONAL BLDG.OR ,r AFFIDAVIT WAIVER [nSeMExT RECORD.IN$TR.NO. DATE F" WORK TO HOUSE SEWER @ $3.00 U lV OVERFLOW SEEPAGE PIT.DRAINFIELD _ a EXTN..CE55POOL.DRYWELL.MANHOLE @ $5.00 ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING H SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT PERMIT NO. i INDUSTRIAL WASTE APPROVAL CHARGES i OWNERS PERMIT z 00 AUTHORIZATION I TOTAL FEE o CONNECTION CHARGE FEE 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 OF 19_ OWNER OR NEW HOUSE SEWER 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 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING [IPLUMBING AND SEWERS. - CESSPOOL ElDRYWELL .I I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR LICENSEDAS 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, .T ABOVE D ED RESIDENTIAL P�RORTY�. gBAND�HOUSE�SEWERSIGNATURE OF PERM E ABANDON OLS ❑ . VALIDATIO JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH ` 9-"' .Cats 4 al. D J4 Y'�