HomeMy Public PortalAbout10228 LIVE OAK AVE_Sewer__ •10-63
76A646A642D APPLICATI FOR PERM _
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEARE
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
FOR APPLICANT TO FILL IN / rLEGALine •DESCRIPTION LOT NO W J
A I L y//' /Op
BLOCK TRACT O L" O AD RE �/ v /� V
Nb OF LOGS L`•
SIZE OF LOT NOW ON LO Q1.�/r GiI CITY ` TEL NO,
USE OF DISTRICT NO GROUP MAP "17
OCES E BY
BUILDINGS
��,/rJ BK iPG
CONTRACTOR ���f r' 3. / G /� 1� /
ADDRESS � �/�r L CONNECTION DATA
CITY � TEL ,N/OV STATION DEPTH
TE
REGISTRATION NO GeO���i Cr J COUNTY MANHOLE REFERENCE
r
NO DESCRIPTION OF WORK FEE YPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO Y CURB PL M L TO P }
PUBLIC SEWER ES 00
SEPTIC TANK,SEEPAGE PIT OR PC NO Q
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PER V
PRIVATE DISPOSAL SYSTEM $300
CONNECTADDITIONAL BLDG OR AFFIDAVIT WAIVER EaSEM[NT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO _
INDUSTRIAL _
WASTE APPROVAL
OWNER$ PERMIT S 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX ISTI DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSP CTOR 5 SIGNATURE
SIGNED THIS DAY OF 19_ ^/
OWNER OR NEW HOUSE SEWER
OWNERS AGENT -
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIRE0 BY LOS ANGLES COUNTY NO STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, NO INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE VE DESCRIBED RFpyDENTI L OPERTY ABANDON HOUSE SEWER
SIGNATURE LS////{ CKFILL SEPTIC TANKS ❑
OF PERMIT SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
bjo 7 3 2 5 APR 17 1 0 D 7.0 0- ry'