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HomeMy Public PortalAbout6040 IVAR AVE_Sewer__ A642D 76A6420-63 APPLICATION, FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION WOR (] �� JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Sup't of Building FOR APPLICANT TO FILL IN LEGAL DESCRIPTION LOT NO. OWNER IA MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF DISTRICT NO. BUILDINGS GROUP MAP PROCESSED BY _ BK PG C-(T-W R AA A� ADDRESS �� _ CONNECTION DATA ] CITY TEL. NO. ` STATION II _ R a�l�b DEPTH PYA �� ❑ COUNTY ilk Fy� {ti\ \J UP ER REGISTRATION NO. MANHOLE REFERENCE OWER NO. DESCRIPTION OF WORK FEE TYP O ECTION LENGTH FROM HOUSE SEWER CONNECTING TO R P.L. M.L.TO P.L. 7 } PUBLIC SEWER & S5.00 d SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. P.C.NO. O JOB NO. PITS AND/OR DRAINFIELD @ $10.00 ' V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N / w PRIVATE DISPOSAL SYSTEM @ $3.00 / 0 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 V OVERFLOW SEEPAGE PIT,DRAINFIELD W EXTN..CESSPOOL.DRYWELL,MANHOLE @ $5.00 R H ALTER, REPAIR OR ABANDON HOUSE - SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCR ACHMENT I PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ 21 Oo " CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM IID 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 V ADDRESS BUILDING OR WORK I HEREBY ACKNOWLEA E HAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S) AND STATE THAT THE OVE IS CORRECT AND AGREE TO COMPLY ' AND/OR DRAINFIELD WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR 'J 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, THE ABOVE DE ij RESID TIAL OP ERTY. ABANDON HOUSE SEWER SIGNATURE OF PERMITTE BACKFILL SEPTIC TANKS ❑ ❑ _ i SEEP.PIT(S) ❑ CESSPOOLS -?-----,:VALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER CK. 6A642 0-63 APPLICATION ICO® PERMIT 7 6 A 642 D /`i Q�If�IL i'Y 0 I tl FOR f'�IG GY I V II COUNTY OF LOS ANGELES SEWER—SEWAGg DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING �) JOHN A. LAMBIE, County Engineer ADDRESS VI �• WILLIAM A. JENSEN, Sup't of Building LOCAL;TY ._ .. _.... _ NEAREST q ` FOR APPLICANT TO FILL IN CROSS sT. LEGAL DESCRIPTION LOT N OWNER MAIL BLOCK TRACT ADDRESS NF BLDG SIZE'OF LOT NOW LO CITY TEL. NO. - USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY BK PG 11 CNT O .� ADDRESS CONNECTION DATA It CITY TEL. NO. TION 6 © + P REGISTRATION NO. (� ��Z� ElCOUNTY MANHOLE REFERENC E I ref LOWE NO. DESCRIPTION OF WORK FEE TYPE F C ECTI N J ItD LENGTH FROM t HOUSE SEWER CONNECTING TO C P.L. M.L.TO P.L. PUBLIC SEWER @_$5.00 a JJ�� P.C.NO. O SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. ,j 3 .6 JOB NO. PITS AND�OR DRAINFIELD @ $10.00 / V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMITXZ PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEM ExT RECORD.INSTR.NO. DATE VF.. WORK TO HOUSE SEWER @ $3.00 V OVERFLOW SEEPAGE PIT,DRAINFIELD LU EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $5.00 "ya- ALTER.REPAIR OR ABANDON HOUSE HWY. W i G // 9 SEWER OR DISPOSAL SYSTEM @ $3.00 STAftE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNER'S PERMIT s z AUTHORIZATION TOTAL FEE 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_ n OWNER OR - NEW HOUSE SEWER OWNERS AGENT ^ 1 CONNECT ADDITIONAL �l ADDRESS , BUILDING OR WORK I HEREBY ACKNOWLED&E HAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S) 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 ❑ DRYWELL ❑ �i 'LI HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR Y Aj LICENSED AS REQUIRED BY LOS GLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM RE OR THAT I AM THE GOWµ,ELR OF, AN NTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO DESCRIB D R SIDEN IAL PR Y. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ a') OF PERMITTEE CCC SEEP,PIT(S) ❑ CESSPOOLS ❑ ALIDATION ROBERT A. WOOD M.O. CASH SUPERVISING MECHANICAL ENGINEER CK. I o ' o 2 6i' SEPI 6 1 1 A 2 5-00- I��