HomeMy Public PortalAbout9717 LIVE OAK AVE_Sewer__ CE808 D,°-63 APPLICATIO
76AB4 N FOR PER IT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7NEAREST
, J,
JOHN A. LAMBIE, County Engineer (�
WILLIAM A. JENSEN, Sup't of Bu>ldmg p.�
FOR APPLICANT TO FILL IN 7
LEGAL /6�7, ` f
DESCRIPTION LOT NO �( a OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
WF
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA s/
CITY , TEL STATION G_/ t� DEPTH G-
•�/
STATE MANHOLE REFERENCED ./
REGISTRATION NO p���f� COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM i
HOUSE SEWER CONNECTING TO CURB P L M L TO P L
PUBLIC SEWER ES 00
SEPTIC TANCO IMP NO JOB NO K.SEEPAGE PIT OR PC NO O
PITS AND/OR DRAINFIELD @ $1000 J V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
A $300
PRIVATE DISPOSAL SYSTEM @ $3 00 I 4(p
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $300 iV•
OVERFLOW SEEPAGE PIT DRAINFIELD 17J
EXTN,CESSPOOL,DRYWELL,MANHOLE @ ES 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ 5300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00
CONNECTION CHARGE FEE CHARGES
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 SIGNATU E
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER AAS
OWNERS AGENT
CONNECT ADDITIONAL f
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
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
L
NG AND SEWERS CESSPOOL ❑ DRYWELL ❑
EBY CERTIFY T T I AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
D AS RELLLLLL
TY A D STATE OF SEWAGE DISPOSAL SYSTEM
NIA OR F AN INTEND TO DISCONNECT PLUG AND
IN THER ERTY ABANDON HOUSE SEWER
RE �� BACKFILL BE TANKS ❑
RMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
Leo 1 2 8 9 r. MAY 6 1 U D 7,0 Q N