HomeMy Public PortalAbout6123 IVAR AVE_Sewer__ �• t
CE808 3-61
76A 642D
COUNTY OF LOS ANGELES SIEVVER-SEWAGE DQSPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS L�
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO IN CROSS ST.
LEGAL i �✓
DESCRIPTION LOT NO a OWNER
BLOCK TRACT //,�, ,y MAIL f
(: G/ ADDRESS i -
NO.OF BLDGS. w j
SIZE OF LOT NOW ON LOT CIT EL. HO r e!
USE DISTRICT NO. GROUP
BUILDIDI MAP NGS � a K PG PROCESSED BY
CONTRACTOR
ADDRESS -
Comm ATA
CITY TEL.N0.,4 6;`T STATION , L DEPTH
STATE MANHOLE REFERENCE fI UPPER.
REGISTRATION NO. .451 e ® COUNTY
NO. DESCRIPTION OF WORK FE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ s .00 �L TYPE OFC
TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. URB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $1.00
OVERFLOW SEEPAGE PIT,DRAINPIELD d
EXTN..CESSPOOL.DRYWELL @ $ .00
HOUSE SEWER CONNECTING TO I P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ S .00 CO.IMP.NO. JOB NO. V
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ S .00 9 TRUNK PERMIT N0. ROAD PERMIT N0. d'
ALTER,REPAIR
DIISP OR SAL ABANDON HOUSE @ $ 00 STATE ENCROACHMENT O
PERMIT NO. IU
INDUSTRIAL
WASTE APPROVAL to
CHARGES z
OAR'S PERM g 2 00 CONNECTION CHARGE FEE
AUTHORIZATION rTOTAL FEE 6p REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- :.
TRACTOR TO CONNECT THE ABOVE DE>RIBED EXISTING DWELLING APPROVAIeS DATE INSPf.CTOR'S SIGNATURE
TO THE PUBLIC„SEWER.
SIGNED THISDAY OF +6A y+SIGNED J9 NEW HOUSE SEWER
OWNER OR t e CONNECT ADDITIONAL
3 OWNERS AGENT. /9 BUILDING OR WORK
I ./9. SEPTIC TANK,SEEP.PIT(S)
. ADDRES AND/OR DRAINFIELD
I HEREBY ACK OWLEDGE THAT IHAVE READ THIS APPLICATION ,-
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR l DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF - ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED. RESIDENTI L PROPERTY. BACKFILL SEPTIC TANKS ❑ ��/�( /
SIGNATURE
SEEP.PIT(S ❑ CESSPOOLS O
OF PERMITTE
VALIDATION ROBERT A. WOOD
CK. 11.0. WH SUPERVISING MECHANICAL ENGINEER
�, ' S 7 7