HomeMy Public PortalAbout8706 LONGDEN AVE_Sewer__ 3-64
76A643-64
APPLICATION FOR PERMIT'
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION gNEAREST
JOHN A. LAMBIE, County Eng2neer (�
WILLIAM A. JENSEN, Sup't of BuildingFOR APPLICANT TO FIL IN LEGAL DESCRIPTION LOT NO O
MAIL h
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY t TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS •(fes'' BK PG
CONTRACTORrn 6; g ..L�
ADDRESS • ,jQ / CONNECT DATA
CITY O'� '�n TEL NO AT-'7C)`TOY STATION DEPTH
STATE MANHOLE REFERENCE10 UPPER
REGISTRATION NO COUNTY
NO CESCRIPTION OF WORK I FEE TYPE OF CONNECTIONLENGTH FRO
HOUSE SEWER CONNECTING TO Y CURB M L TO P L
PUBLIC SEWER @ S5 00
PC NO
SEPTIC TANK,SEEPAGE PIT OR
CO IMP NO JOB NO
PITS AND/OR DRAINFIELD 51000 O
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASIMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 `
OVERFLOW SEEPAGE PIT,DRAINFIELD i.
EXTN CESSPOOL,DRYWELL MANHOLE @ 1100 VVV
LU
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 9%
S4
EWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT y
PERMIT NO /z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER APPROVALS DATE INSPEC R S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER �•"J , 5�~ L '~
OWNERS AGENT ,
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS I CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF BE
WAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND /
RESIDE IN, THE ABO DESCRIBED REST NTIAL P OPERTY ABANDON HOUSE SEWER
4
SIGNATURE BACKFILL SEPTIC TANKS
T ,I M
OF PERMITTEE e
SEEP PISI ❑ CESSP OLS
ALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
LAC0 8 2 6 6 DED 2 3 1 0 A 7.0 O N a