HomeMy Public PortalAbout10604 LIVE OAK AVE_Sewer__ CES
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78A 842D
COUNTY OF LOS ANGELES SEWER-SEWAGE DIS OSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING • /}
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS y / ve (iL
COLEMAN W. JENKINS, SUP T OF BUILDING
LOCALITY
NEAREST "//
FOR APPLICANT TO FILL IN CROSS ST VL
LEGAL
�DESCRIPTION LOT NO Z/ OWNER
BLOCK TRACT J �- MAIL
ADDRE85 S C4 In
NO BLDG
SIZE OF LOT NOWOON LOTT6 alJ CITY TEL NO.
-�
USE OF D16TRICT MAP PROC SED Y
BUILDINO GROUP NGS �
mL � Iq I B PV
CONTRACTOR
ADDRESS v Y Ye- CONNECTION DATA
CITY •L , TEl NO 6 S 70 STATION DEPTH
I
STATELIC MANHOLE REFERENCE UPPER
LICENSE NO D CLASS
NO DESCRIPTIO OF WORK FEE TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO QV Y CURB P,L M L TO P L
PUBLIC SEWER @ 53 00 PC NO _
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 510 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT covin I EASEMENT I RECORD INSTR NO DATE U
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ 5500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
W
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT a_
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
�
OVVN�EjR'S PERMIT S z 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE m
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO_CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INS CTOR'S I NATURE
if
SIGNED THIS DAY OF 19_ i
OWNER OR 1114 NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DE5jCRIj3E&RESIDENTIAL PROPERTY �BACKIILL
BANDON HOUSE SEWER
SIGNATURE ❑OF PER MiTTEE SEPTIC TANKS QEEP PIT(S) El CESSPOOLS /
VALIDATION JACKf JACKR. ALLEN
cK I M o CASH SUPERVISING MECHANICAL ENGINEER
�. �1 75 �� 1 �'.1 o D ?.00