HomeMy Public PortalAbout6201 IVAR AVE_Sewer__ 64 20 5-65
76AAPPLICATION FOR P _ER T
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOIIN A. LAINIBIE, County F"ngineer ADDRESS
COLEMAN 1l'. JENKINS.Supt. of Building
LOCAL iTY
NEAREST
FOR APPLICANT TO FILL IN7 CRDSB ST.
el
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL.
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF v
DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
BUILDINGS
CONTRACTOR O �/ 9
ADDRESS CONNECTION DATA
'CITY J J J`/�EL. NO. - - STATION / 79�J DEPTH
LICEN - /•-�-� LICENSE CJ
NO. LASS C� MANHOLEREFERENCE G^j
��T LOWE
NO. 1 DESCRIPTION OF WORK FEE TYPE OFCTION LENGTH FROM� �
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER C $ 5.00 �+
SEPTIC TANK, SEEPAGE PIT OR +_1^ P.C.NO. n,
PITS AND/OR DRAINFIELD C $1 0.00 CO.IMP. NO. 1 J 3 JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.lq-- U
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT wAIVEF EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER C $ 3.00
L , RE A R OR ABANDON HOUSE (,J
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
V HWY.OR ST.WIDENING D.
EXTN.,C ES SPOO L, MANHOLE C $ 5.00 hy
STATE ENCROACHMENT 6
PERCOLATION TEST C $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 2 00 CHARGES
AUTHORIZATION TOTAL FEEJJ 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 SEWY&. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW.HOUSE SEWER
OWNERS AGE. CONNECT ADDITIONAL
Y-
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
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
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY 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 T . I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE BOV DESC IBED RESIDENT I PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMITTE HACKFI.LL SEPT ANKS q
SEEP,PIT(S) 9AEL-SPOOLS Y
� ALIDATION
CK. M.O. CASH
Arm 4 9 01" wl2 1 0 D 7.0 ON
76.A 6 2/70 APPLICATION FOR PERMIT
76,A 642 D APPLICATION�7 A- a..
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
.DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Ij U
yBILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS J GI
COLEMAN W. JENKINS, SUPT. OF BUILDING
11 LOCALITY
r~ FOR APPLICANT TO FILL IN NEARECROSS SST.
(PRINT OR TYPE ONLY)
LEGAL y
! DESCRIPTION LOT NO. _3 OWNER �- S
r►"� MAIL _ a70
BLOCK TRACT `� ADDRESS
NO. OF 6LD.GS.
SIZE OF LOT NOW ON LOT CITY- � EL. NO.
SE OF DISTRICT NO. GROU CLA55 MAP PROCESSED BY
BUILDINGS SK PS
/i/. ,Q
CONTRACTOR. /
ADDRESS CONNEC IOPI DATA
�7C.y STATION DEPTH
ICUITS�1/5t,PTEL. NO. 4
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO:� GLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC'TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 - CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL�'� AFFIDAVIT WAIVER 'EASEMENT RECORD.INSTR,NO, DATE
WORK TO HOUSE SEWER @ $3.00 - U
OVERFLOW SEEPAGE PIT.DRAINFIELD ix
O
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
H WY. OR ST.WIDENING
TER.����R^ ^'^^"HOUSE
F
SEWER OR DISPOSAL SYSTEM U.06 STATE ENCROACHMENT ti V
C.G w
PERMIT NO. 4 d
INDUSTRIAL j
>�' C WASTE APPROVAL u L_
WNER'S PERMIT S 2 �0.0.�^
CHARGS
AUTHORIZATION TOTAL FEE ` V v 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
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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 REg RED BY f05 ANGLES COU NTV STATE OF
CALIFORNIA OR TIFiA I AM E LEGAL WNER OF, dJ INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE B VE D RIBED ENTIAL O RTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE I BACKFILL SEPTIC TANKS ❑
SEEP.PIT IS) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
CK
M.O. CASH
SUPERVISING MECHANICAL ENGINEER '
i Ap- 0 8 6 7- UUN 15 1 0 -D 5.00-