HomeMy Public PortalAbout6157-59 IVAR AVE_Sewer__ -62
7CESOB
6A642D APPLICATION FOR PERMIT
6A642
- COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BU ILDING
JOHN A. LAMBIE, County Engineer ADDRESS a7J/ ssi
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
-,..:. ..-. ...-,.-.,.. ..:.. ._. NEAREST P
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL j
DESCRIPTION LOT NO. Y J OWNER Yr
BLOCK TRACMAIL
T ADDRESS
NO. OF BLDGS. �
SIZE OF LOT NOW ON LOT CITY a / TEL. NO
USE OF DISTRICT O. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
jV
CONTRACTOR
ADD
RESS � ��� CONNECT ATA
CI [/ EL. NO ;/U STATION DEPTH' STATE MANHOLE REFERENCEUPPER
REN NO. /// �—f ❑ COUNTY . •LOWER,
NO. DESCRIPTION OF WORK FEE TYPE OF C 'J(.T+ION LENGTH FROM
HOUSE SEWER CONNECTING TO ® Y. CURB 3 P.L. M.L.TO P.L.
'PUBLIC SEWER @ $5.00 O
SEPTIC TANK,SEEPAGE PIT OR @P.C.NO.
PITS AND/ DRAINFIELD $10.00 CO.IMP. NO. JOB NO. U
HOUSE SEWER CONNECTING TO 4
TRUNK PERMIT.NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3.00 �(��✓
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAly Ex EasEM E>VT RECORD.INSTR.NO': DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD '
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING sy
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
_ PERMIT NO. -
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i Oo CHARGES
AUTHORIZATION TOTAL FEE i7 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE �•
TRACTOR TO CONNECT THE ABOVE DESCR)9ED EXISTING DWELLING
TO THE PUBLIC.SEW APPROVALS DATE INSf�ECTOR'S SIGNATURE
SIGNED THIS' -DAY 0F 190• . - / s
OWNER OR / ° � NEW HOUSE SEWER �
OWNERS AGENT �✓/ ` -.E-,/ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
l
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ' 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
a RESIDE IN, THE ABOVE',DESCRIBED RESIDENTIALPROPERTY. ABANDON HOUSE SEWER
SI OF APERMiTTEE /4✓.eG•// ,✓ �4 !! �'f./� BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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