HomeMy Public PortalAbout9232 LIVE OAK AVE_Sewer__ 5.65
76A645-65
APPLICATION FOR PERMIT
76A 64 I I
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL IUI
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING f� /� �•� v�
JOHN A. LAMBIE, County Engineer AODRES. �!) �/ Z
COLEMAN W. JI NKINS,Sup't. of Building P r�
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL i
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT (/ J ADDRESSNO. BLOC .
A �T♦M n OA
SIZE OF LOT NOWOON LOTS CITY r/?9 PL 4 J''EL. NO.:2 61 13
USE OF
DINGS DI
LDISTRICT NO. GROUP MAP PROCESSED BY
BUI
CONTRACTOR /// /i0//�,://// �!'�� -•J^ B `/ PG
ADDRESS ,C+, CONNECTION DATA
CITY TEL. NO. �� STATION ,! DEPTH /
LICENSE ) LICENSE 7" UPPER
NO. �/� � CLASS �. MANHOLE EF ;ENCS .. � LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OF ISCNEGTION LENGTH FROM
HOUSE SEWER CONNECTING TO ,Y- Y. URS P.L. M.L.TOf '
PUBLIC SEWER C $ 5.00 v
SEPTIC TANK. SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $1 0.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM C $ 3.00 9x
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER C $ 3.00
lTrTER_,_REPAIR OR ABANDON HOUSE (�
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
LOWSEEPAGE IT, DRAINFIELD - HWY. OR ST.WIDENING y�
E X T N.,C E S SPOOL, MANHOLE C $ 5.00 STATE ENCROACHMENT b
PERCOLATION TEST @ $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $! i 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'I 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 INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ y _
OWNER OR NEW HOUSE SEWER (/
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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
LICENSEDAS 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 DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE L y, ElOF PERMITTEE �i��/LOJ9C.Qwif_� BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION
CK. M.O.
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