HomeMy Public PortalAbout9174 JAYLEE DR_Sewer__sewer connection D
S&E-6ss it•ss APPLICATION FOR PERMIT 5
f& •s
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING 'Y �j
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO, lr'
MAIL
BLOCK — TRACT f / �' ,',. ADDRESS
NO. OF BLDGS. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS .? DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS —
��—
CITY TEL. NO. STATION ,' DEPTH
- r, - — �--
MANHOLE REFERENCE _ UPPER
[]'STATE LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE - - --
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO.IMP.NO. JOB NO.
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00 -
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 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 RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(5) ElCESSPOOLS El
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINE6 VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.O. CASH