HomeMy Public PortalAbout9711 LIVE OAK AVE_Sewer__ 10-63
76A6420 APPLICATION
PP ACAION FOR PERMIT
cOUNTY•OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION4NEARE
ING
JOHN A. LAMBIE, County EngineerSS
WILLIAM A. JENSEN, Sup't of Building
ITY ST ofFOR APPLICA T TO FILL IN ST.
LEGAL �Q
DESCRIPTION LOT NO "� V OWNER
/
BLOCK TRACT/_—j-0j T �{ LO ADDRESS V
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY �� TEL. •NO.
USEOF a DISTRICT NO, GROUP MAP PROCESSED BY
BUILDINGS
J'B K�' PG
CONTRACTOR
ADDRESS - ,�, , CONNECTION DATA
CITY l TEL, STATION / •�..- DEPTH
/J ✓J q STATE MANHOLE REFERENCE
REGISTRATION NO, OL.-®'p��P*�� ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR ` �y P.C.NO. a•
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. J U JOB NO. Q
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N$/ V
PRIVATE DISPOSAL SYSTEM @ $3.00 { IX
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEF EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD IV
EXTN.,CESSPOOL,DRYWELL.MA NH OLE @ $5.00 a
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING to
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'IHAVE 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 THISDAY 19_ /r/
OWNER OR NEW HOUSE SEWER t !
OWNERS AGENT__ I+ a
CONNECT ADDITIONAL !j L
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT IS)
I 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 ❑
f I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLE��F Co. SEWAGE DISPOSAL SYSTEM
CALIFORN HAT I AM THEI�L DISCONNECT PLUG ANDRESIDEHE ABOVE DE5CRIB ESIABANDON HOUSE SEWER
SIGNATU BACKFILL SEPTIC TANKS ❑
OF PER EE - SEEP,PIT IS) ❑ CESSPOOLS ❑
VALIDATION-"\ ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
12138 MAY ,D D 7,00