HomeMy Public PortalAbout10524 LIVE OAK AVE_Sewer__ CE808 3-61
APPUCA MN POR
76A 642 D M
COUNTY OF LOS ANGELES SEWER-SEWAGE ®BSPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building_ LOCALITY
_ 7 NEAREST
FOR PiPPLICAPIT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N OWNER
BLOCKTRACT MAIL
ADDRESS
0. BLDGS.
SIZE F LOT W ON LOT " '
CITY TEL NO
USE OF � '
BUILDINGS DIST NO. GRO' BK PO MAP PROCESS Y
CONTACTOR v
f f
ADDRESS CQJIJNECTIQIIJ ATA
} -�a�/
CITT / TEL.NO. 1 t STATION DEPTH
REGISTRATION NO. / COUNTY MANHOLE REFERENCE UPPER
LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO 9
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR i Y. Cupm P.L. X.L.TO .L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DAlNF1ELD a
EXTN. CESSPOOL DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO TCO . N0. JOB NOO. UO
PRIVATE DISPOSAL SYSTEM $1.00
CONNECT ADDITIONAL BLDG.OR
ORK TO HOUSE SEWER 00 TRUNK PERMIT N0. ROAD PERMIT N0.
° W
ALTER,SEWER REPAIR R @ $1 00
ABANTN HOUSE STATE ENCROACHMENT O
PERMIT NO U
INDUSTRIAL a
WASTE APPROVAL to
CHARGES z
OWNEWS PERMIT 3 2 OO CONNECTION CHARGE FEE
AUTHORIZAnON 1 TOTAL FEE 0'D REIMBURSEMENT FEE
IHAVE AT CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGS DAA CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS A DAY OR 19_[ALTER.
HOUSE SEWER A
OWNER OR /,�j®�A/' NECT ADDITIONAL �1� /�
OWNERS AGENT 44Z .// LDING OR WORK i /
- TIC TANK,SEEP.PITS) J
ADDRESS /OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT l HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING REPAIR,SEWER OR
PLUMBING AND SEWERS. AGE DISPOSAL SYSTE
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUN_TX AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR HAT 1 AM THE LEGAL OW OF THE ABOVE
DESCRIBED RES" I PBACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT S [ICESSPOOLS
OF PERMITTEE
AnON ROBERT A. WOOD
0 M.0. GSR SUPERVISING MECHANICAL ENGINEER
LiCol 5 8 O,Qi JUL 13 1 0 o 5.00- V