HomeMy Public PortalAbout10101 LANDSEER ST_Sewer__ CE808
76A 642D42D APPLICATION FOR PERMIT
78 '
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING /O tl
JOHN A, LAMBIE• County Engineer ADDRESS
WILLIAM A. JENSEN. Sup't of Building LOCALITY f
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER FL
DESCRIPTION LOT N0.
MAIL
BLOCK TRACTADDRESS ADDR a T �j
Iio'OF BLDGS. T
SIZE OF LOT NOW ON LOT CITY TEL. pj
USE OF
BUILDINGS DISTRICT N0. GROU MAP PROCESSED BY
� - BK-. P13
CONTRACTOR 112f 0i
Qr
ADDRESS CONNECTION DATA
CITY ,• /V4tiC TEL.NO. -2 5! STATION DEPTH
gy
SLATE MANHOLE REFERENCE
REGISTRATION NO. C — — A B COUNTY
No. DESCRIPTION OF WORK FEE I
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 AQ TYPE OF CONNECTIO LENGTH FROM
SEPTIC T /
ITS AND/NK,OR S EPAGELDT OR @ 53.00 Y. CURB P.L. I.L.TO P.L. 30
OVERFLOW SEEPAGE PIT.DRAINFIELD >_EXTN..CESSPOOL.DRYWELL $2.00 IL
HOUSE SEWER CONNECTING TO P.C.NO. J O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK
TO HOUSE SEWER @ S1.00 w
SEWER OR DASPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL {JJ
WASTE APPROVAL li
N
CHARGES
OWNIERrS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBE EXISTING DWELLING APPROVALS D TE INSPECTOR'S SIGI�AT1�tE
TO THE PUBLIC SEW �//��
SIGNED THIS AJ 18�£c NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT f BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
t HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
CE
LINSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT THE LEGAL OWNE OF THE ABOVE
DESCRIBED OR THAT PR RTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE
VALIDATION ROBERT A. WOOD
clL
M.o. ustl SUPERVISING MECHANICAL ENGINEER
s�7 1 6 1 ' JAN 17 1 0 D 5.0 0 u-