HomeMy Public PortalAbout9856 LEMON AVE_Sewer__ t e
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76A6423-61
APPLICATION FOR PERMIT
8A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION fBULDINJOHNA, LAM M, County EngineerDRESSWILLIAM A. JENSEN, Supt of Building ALITYARESTFOR APPLICANT TO FH1 IN OSS ST.
LEGAL OWNER MAIL
DESCRIPTION LOT N0.
BLOCK TRACT ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF
BUILDINGS ��� DISTRICT N0.I Gk MAP P ESSED BY
CONTRACTOR �jr D Y
ADDRESS pe✓ C NNECTION DATA
CITY TEL.NO. y p� STATION DEPTH
h e STATE MANHOLE REFERENCE / UPPER,/
REGISTRATION NO. !i COUNTY c
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 TYPE OF CONNECT LENGTH FRO
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $8.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2.00 IL
HOUSE SEWER CONNECTING TO P.C.NO. � O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO,IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. a'
WORK TO HOUSE SEWER 51 00
SEWER 0 REPAIR
DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT O
PERMIT NO. IV
INDUSTRIAL CL
WASTE APPROVAL h
CHARGES ?
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 1-51040 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS D TEI INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 9- NEW HOUSE SEWER
OWNER OR d CONNECT ADDITIONAL
OWNERS AGENT . r BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S) !
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I. 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
LDESCRIBED
G AND SEWERS. SEWAGE DISPOSAL SYSTE14
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
NIA OR THAT 1 M THE LEGAL OWNER�F THE ABOVE BACKFILL SEPTIC TANKS ❑
RESIDENTI ROPERTY. q f SEEP.PIT(S ❑ CESSPOOLS
RE /
MITTE
VALIDATI ROBERT A. WOOD
CK, M.o. CASH SUPERVISING MECHANICAL ENGINEER
6 3 0'3" DEC 1 g 1 0 D
5:0.0
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