HomeMy Public PortalAbout6042 IVAR AVE_Sewer__ CE808 10-63
7 6 A 642 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELESGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
SEWER- EWA
BUILDING AND SAFETY DIVISION BUILOINc a �
JOHN A. LAMBIE, County Engineer
ADDREss
WILLIAM A. JENSEN, Supt of Building
LOCALiTV i
._ NEAREST
FOR APPLICANT TO FILL IN CROSS ST. ^
LEGAL
DESCRIPTION LOT NO. �� OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
(��/B�7�K (�']/SPG
CID
ADDRESS r- /( tj CONNECTION DATA
CITYTEL. NO. �3 STATION DEPTH
• SCa
' ❑ STATE MANHOLE REFERENCE /g UPPER
REGISTRATION NO. (�/ ❑ COUNTY ! 4:• LO R
N0. DESCRIPTION OF W RK FEE TYPE OF CTION LENGTH FROM •3
HOUSE SEWER CONNECTING TO Y�„i Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR iy !� P.C.NO. d
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. 13:!) 'JOB NO. / O
N
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
A / V
__PRIVATE DISPOSAL SYSTEM @ $3.00 EC/
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD,INSTR,NO, DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD
E HWY.OR ST.WIDENING C
XTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 UJ
ALTER.REPAIR OR ABANDON HOUSE h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00
� CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
1HAVE 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 AY OF 19_ n
�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT ( U
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(5)
I HEREBY ACKNOW LED E HAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE! 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
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 I AM THE LEGAL OW R OF, A D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE D CR'rB ED RE
T AL PR ERTY. ABANDON HOUSE SEWER
SIGNATURE f BACKFILL SEPTIC TANKS ❑
OF PERMITTE
SEEP,PIT(S) ❑ CESSPOOLS ❑
0.K
M.O. CASH ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
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