HomeMy Public PortalAbout8640 LONGDEN AVE_Sewer__ 76A64 4/72 APPUCATION FOR PERMOT ' I
76 A642L Y`�r /�► 1 �\7 r �V� 1 'uf
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS [)
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T / /d
' AL
DESCRIPTION LOT NO L ' 3 �+�' OWNER !L/ - /���G� / •(�3�4�
MAIL
BLOCK TRACT ADDRESS
NO OF BLOG6 c -�
SIZE OF LOT NOW ON LOT CITY .S/� � TEL NO K; _�
USE OF BUILDINGS DISTRICT NO GROUP MAP PR CESSED BAY
B K p G
IONTRACTOR `
ADDRESS �j� �/,�/lyCONNECTIO DATA
CITU 4 11 0446.0^ TESL NO eO7;7S STAT ION �.�DEPTH �~
LICENAT ESE NO � u3- "" GLASS 7 MANHOLE REFERENCE D� u _
(� LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO �)G Y CURB P L ML TO P L QG
PUBLIC SEWER @ C/
P C NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
FRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIY[R EASEMENT RECORD INSTR NO DATE ce
WORK TO HOUSE SEWER @0
OVERFLOW SEEPAGE PIT DRAINFIELD ~
EXTN CESSPOOL DRVWELL MANHOLE @ W
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING d
SEWER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMTT s 7J
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 00
IHAVE AT THIS DATE A CONTRACT WITH THE HER IN 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_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONrABAN
SEPTIC TANK SEEP PIT(5)
AND STATE THAT THE�ABO CORRECT AND AGREE TO COMPLY DRAINFIELD
WITH ALL COU N�Y�'OINANCES NO STATE LAWS REGULATING
PLUMBING AANDEEWEROL ❑ DRYWELL ❑
I HERF_BV CERTIF I AM ROPERLY REGISTERED AND/ORREPAIR SEWER OR
LICE D A UI �BY LOS ANGLES OUNTY AND STATE OF DISPOSAL SYSTEM
CA F A O T I AM TH EGAL NER OF AND INTEND TONECT PLUG AND
IDE IN T AB DES D SI DENTIAL PROPERTY N HOUSE SEWER
SIGNA E _ JiC`i4 L SEPTIC TANKS
❑
PERM T !� G.G" TIS) ❑ CESSPOOLS ❑
VALIDATION
CK M 0 CASH
0 „, AR. 14 1 A 1 0.0 0 ®98