HomeMy Public PortalAbout9048 LONGDEN AVE_Sewer__ 76A64 2D 5-65 APPLICATION FOR PERMIT C�
76A64u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LANIBIE, County Engineer ADDRESS
COLENIAiN W JENKINS.Sup't of Building
LOCA Li TY
NEARES
FOR APPLICANT TO FML IN CROS 6 T
LEGAL
DESCRIPTION LOT NO �V( OWNER
MAIL ++�
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CI V L NO
USE OF
BUILDINGS ) DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CO NT RA CTO f J5.1
ADDRESS CONNECTIO/N DATA
CI TEL N STATION / EPTH
LICENSE .�/Q / LICE NSE< �- UPPER
NO / / �� CLASS MANHOLE REFERENCE
f
NO DESCRIPTION OF WORK FEE TYPE OFC TION LE GTH FR
HOUSE SEWER CONNECTING TO pO Y CURB P L M L TOP L19
PUBLIC SEWER @ $ 5 00
SEPTICAN EE G PC NO d
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EAS MERT RECORD INSTR NO DATE
WORK TO HOUSE SEWER C $ 3 00 0
'
SEWER OR DISPOSAL SYSTFMHO SE @ $ 3 00 V
HWY OR ST WIDENING Ya
EXTN ,CESSPOOL, MANHOLE @ $ 5 00 STATE ENCROACHMENT
PERCOLATION TEST @ $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00
TOTAL FEE OCA CONNECTION CHARGE FEE CHARGES
AUTHORIZATION
I HAVE AT THIS DATE A CONTRACT WI E HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE D CRI D EX TING OWELLIN
TO THE PUBLIC SE� APPROVALS DATE INSPECT 'SSIGNATURE
SIGNED THIS DAY OF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGEN
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEGAL OWNER OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB DESC ED R SIDENTIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ ' i _1
OF PERMITTEE SEEP PIT(5) ElCESSPOOLS ❑ /�
f �
VALIDATI0)*------,
CK M O CASH
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