HomeMy Public PortalAbout6002 IVAR AVE_Sewer__ ' a
CEBDB 3-62
76A 642D APPLICATION/�TION FOR ERK41T
A� rr� 4 �V
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 6u ILOI NG
JOHN A. LAMBIE, County Engineer ADDRESS 00 N ZVD.r
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST Ter-pie
R APPLICANT TO FILL IN CRO88 ST. G
LEGAL _ (Y T,1
DESCRIPTION LOT NO. (^rr _ OWNER Mr. CS. loll l7 1�
�j/-- - MAIL TT7 'TI'
BLOCK Liu TRACT ADDRESS 6002 I. i a.
SIZE OF,LOT i I NOW OON LOTS CITY 1" Z TEL. NO. A,y 6— G
49
USE OF Res id.enCe DISTRICT NO. GROUP MAP P" CE BY
BUILDINGS
BK PG
J CONTRACTOR eT D Plumbing Co
ADDRESS CONNECTION DATA
CITY,, an Gabriel TEL. NO. AT —0 STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. 12693% COUNTY LOWER
NO. DESCRIPTION OF WK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. OB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD RMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT- WAIVER EASEMENT RECORD.'INS NO, DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $5.00 HWY.OR ST.WIDENIN
ALTER. 6w
SEWER SYSTEM @ $3.00 on STATE ENCROACHM T
PERMIT NO.
.. INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z 00 CHARGES
_
AUTHORIZATION TOTAL FEE . 1 5c OO 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
f SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PITS)
1 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 ElDRYWELL El
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF _ SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A4ED
LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND --
RESIDE IN. BOYRESIDENTIA OPERTY. / ABANDON HOUSE SEWER
SIGNATURE ate. �. / •/
OF PERMiTTE r BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION_ ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
- CK. M.O. CASH -