HomeMy Public PortalAbout6112 IVAR AVE_Sewer__ 2.
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76AA642D (LAP ICA 1 ION FOR PERMIT64
COUNTY OF LOS ANGELES SEINER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LA\IHlli;, County Engineer ADDRESS
COLEMAN tC'. JENKINS, Sup't. of Building
LOCALITY
NEAREST
FOR APPLICANT/TO FILL IN CROSS ST. A
LEGAL U '
DESCRIPTION LOT NO '� OWNFtR -- ww.•CC
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW N LOT CITY A l TEL. NO.
USE OF DISTRICTNO. GROUP MAP PROCESSED BY
BUILDING B P
G
CONTRACTOR
ADDRESS CONNECTION DATA/ .
CITY TEL. N STATION / .j f DEPTH G
LICENSE ENSE /REUPPER
NO. CLASS MANHOLE REFENCE
NO. GESCRIP VV_FPIIVV��OF WORK FEE TYPE OF •TION LENGTH FROM
HOUSE SEWER CONNECTING TO �^ Y. CUR P.L. M.L.TO P.L.
PUBLIC SEWER @ $ 5.00
SEPTIC TANK, SEEPAGE PIT OR P.C.NO. d
PITS AND/OR DRAINFIELD @ $1 0.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT .��
PRIVATE DISPOSAL SYSTEM C $ 3.00 cx
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $ 3.00
'ALTER, RE AI R ABANDON HOUSE L)
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
HWY.OR ST.WIDENING d
yy
E%T N.,CESS POOL, MANHOLEN
@ $ 5.00 STATE ENCROACHMENT b
I PERCOLATION TEST @ $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE e7 r— CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. Q REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWE IN
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY On
OWNER OR NEW HOUSE SEWER --
OWNERS AGENT CONNECT ADDITIONAL /
BUILDING OR WORK (-6 i C �
ADDRESS
SEPTIC TANK,SEEP,PITS)
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
PLUMB AND SEWERS. CESSPOOL ❑ DRYWELL ❑ ,
I R Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LI NSE AS REQUIRED BY LOS ANGLES COUNT D STATE OF SEWAGE DISPOSAL SYSTEM
C IFC) NIA R THAT I THE LEGAL NER O , D TEN TO
SID I b 0 DESCRIBE R IDENTIAL P Y, DISCONNECT PLUG AND
ABANDON HOUSE SEWER
OF BACKFILL
_ ESSPOOLSLS � •s !'�,{�'/, 11'""G,r
V IDATION
CK. I M.O.. CASH
nn;, o 7 2 5� &'N30 1 a 1 O O0