HomeMy Public PortalAbout9186 JAYLEE DR_Sewer_6/21/1961_sewer connection • r
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76A642D A11 0 LILY ^ Y �O V FOR PEIJ ll IIVd .
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F
. l
JOHN A. LAMBIE, County Engineer 1
WILLIAM A. JENSEN, Sup't of Building FOR APPLICANT TO FILL IN f� n i
LEGAL OWNER All t✓!T B�
' DESCRIPTION LOT N0.
J BLOCK TRACTMAIL
, � � ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.. - 5USE OF 9
BUILDINGS n;.�,i+r .,�„ .,� DISTRICT NO. GROUP HK PG MAP PR ESSEDBY .
y, CONTRACTOR � �+
Tz �r?f r ntanilr• Avr- I i
ADDRESS .- v v` CONNECTION DATA
0. r I `"
r •" STATION -�- 1 DEPTH .
CITY r TEL.N0. � .Y
STATE I
.r REGISTRATION NO. i J ❑ COUNTY MANHOLE REFERENCE / 0` \ '�/ UPPER
NO. DESCRIPTION OF WORK FEE C�
HOUSE SEWER CONNECTING TO
PUBLIC_SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROM.
SEPTIC TANK,SEEPAGE PIT OR '- Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL, DRYWELL @ $2.00 -
HOUSE SEWER CONNECTING TO P.C.NO. -
PRIVATE DISPOSAL.SYSTEM @ $1.00 CO.IMP. NO. S D JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. O
WORK TO HOUSE SEWER @ $1.00 V
SEWER OR D SP OR ABANDON SAL SYSTEM HOUSE' @ $1 00 STATE ENCROACHMENT O
' PERMIT N0.
INDUSTRIAL V
9 WASTE APPROVAL W
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE q REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-. '> _.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING.DWELLING "•: APPROVALS DATE INSPECTOgSSIGNATURE
G TO THE PUBLIC SEWR. r. c �
r. SIGNED THIS DAY F L- 19&�:. NEW HOUSE SEWER
r: OWNER OR ��`f /9 CONNECT ADDITIONAL
OWNERS AGENT _•�•'�s BUILDING OR WORK -
ADDRESSSEPTIC TANK,SEEP.PIT(S)
'+ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE 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
PLUMBING AND SEWERS. ALTER.REPAIR,SEWER OR -
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED B LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT)•1 AM THE LE' L OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDE PROPERTY. BACKFILL SEPTIC TANKS ❑ c �f'4'�'� n �� .
SEEP. PIT(S) ❑ CESSPOOLS ❑D ,y'�'�1i \ -
SIGNATURE
OF PERMITTEE �'
OF ALIDATION ROBERT A. WOOD
C
M.0. CASH - SUPERVISING MECHANICAL ENGINEER -. -