HomeMy Public PortalAbout9015 JAYLEE DR_Sewer_8/3/1955_7395 sewer connection 76A642D
6 @ E•663 12.54 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer Ion
County of LOS Angeles BUILDING
WM. J. FOX, COUNTY ENGINEER ADDRESS _
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNE
BLOCK TRACT MAIL
ADDRES
NO. OF BLDGS.
SIZE OF L07 NOW 9FNjLOT CITY TEL. N
4
USE OF
BUILDINGS DI TRICT No. I GROUP MAP I
PG
CONTRACTOR �— -
ADDRESS G i� CONNECTION DATA
CITY 0. STATION
�/ y ,� DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY �L�' "'�w UPPER bbmhGi..
TYPE OF CONACCTION LENGTH FROM
No. I DESCRIPTION OF WORK FEE 00*dk- P.L. M.L. TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER (1 $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR
_ W'ORK TO HOUSE SEWER 1.00 CO. IMP. NO. ' ( JOB. NO.
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ P.ND,O_R DIS_POSAL_SYSTEM _ 1.00 I PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
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CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT 5 i 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS D F fel NEW HOUSE SEWER t {
OWNER OR i r CONNEC'GADDI7IONAL
T
OWNERS BUILDING OR WORK
W
SEPTICTANK, SEEP, PIT(S)
ADDRESS — AND/OR DRAINFIELD
I HEREB ACKNOWLEDGE THAT I AV R HIS APPLICATION CESSPOOL❑ DRYWELL[I
AND STATE THAT THE ABOVE IS COR E AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AN STAT LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P PERTY. BACK ('
/ / -f. SEEP.FILL PIT(S)POCCESSPOOOLS �-�v '�
STANKS IGNATURE (/
OF PERMITTEw=1 /
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION I
BY E0' AUG 3 4 4.5 -)
DEPUTY DEPUTY
l ® DEPUTY DEPUTY