HomeMy Public PortalAbout9067 LONGDEN AVE_Sewer__ 76AG410-02 APPUCATIOAI FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL I�fl
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION f
UILDING
JOHN A. LAMBIE, County Engineer DDRESS
WILLIAM A. JENSEN, Sup't of Building
OCALITY
FOR APPLICANT TO FILL IN ROSS 5T
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO O BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO -�
USE I DISTRICT NO GROUP MAP P OC ESS ED BY
BUILDINGS BK PG
CONTRACTOR L
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM }
a
HOUSE SEWER CONNECTING TO Y CURB P L TO PL 0
PUBLIC SEWER @ E5 00
SEPTIC TANK,SEEPAGE PIT OR PC NO V
PITS AND/OR DRAINFIELD 51000 CO IMP NO JOB NO
C
HOUSE SEWER CONNECTING TO N N PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR ^` AFFIDAVIT WAIVER SEMENT RECO D INSTR NO D E W
WORK TO HOUSE SEWER @ $300 4.
OVERFLOW SEEPAGE PIT,DRAINFIELD to
EXTN C ESSPOOL,DRYWELL,MANHOLE @ $500 Z
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHA FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. . REIMBURSE NT 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
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
. AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND -
RESIDE IN, THE OVE DES RI ED RE E TIA PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK M o caSH SUPERVISING MECHANICAL-ENGINEER
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24650 INSERTS
CEEI
0
766642D A®® I AAp- I O V' FO R. PERMIT
COUNTY OF LOS ANGELES
- SEWER—, SEWAGE ISPOSAL`.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING U
JOHN A. LAMBIE, County Eag�nBei ADDRESS
WILLIAM A. JENSEN, Sup't of Building `LOCALITY ;s
,NEAREST - -�
FOR APPLICANT TO FILL IN .CROSS.s
LEGAL /
DESCRIPTION' LOT NO OWNER 4. -
..,sem-'G�',�,/ '
BLOCK TRACT MAIL
' 'ADDRESS
NO OF BLDGS. '
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE D
BDISTRICT NO. GROUP MAP PRO SSED.BY:
UILDINGS r / ® _ I BK CSG
CONTRACTOR
ADDRESS C69MCTION 3JATA
C TY TEL N0. �J STATION DEPTH
f TATE MANHOLE REFERENCE UPP
REGISTRATION N0. G�/ �• OUNTY
r
No; DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER C � r TYPE OF CONNECTI LENGTH FROM
P TS AND/OR'DRAINFSEPTIC TANK GELDDE T OR @ $S OO Y. CURB P.L. M.L.TO P.L.
13-3
_ OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. NO. JOB NO. "f •' W
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO, O
WORK TO HOUSE SEWER @ $1 00 U
SEWER OR PAIR OR
SYSTEM HOUSE @ $1 OO STATE ENCROACHMENT _ pi
PERMIT NO O
INDUSTRIAL
WASTE APPROVAL W
CHARGES V2'
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 7 .C7 C/ REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED,CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBEDEXISTING DWELLING APPROVALS <, DATg INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW �l J / /�
SIGNED THIS- DAY OF �-� 9 NEW HOUSE SEWER ) ICJ /
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT,I BUILDING OR WORK !' -
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I'HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS-APPLICATION - - - - - - -
'AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL '
WITH ALL, COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED- AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN PROP TY. BACKFILL,SEPTIC TANKS ❑
SIGNATURE - SEEP PIT(S) ❑_CESSPOOLS
OF PERMITTE r
®P VALMATIO ROBERT Pi. WOOD
CK. M.0.- CASH SUPERVISING MECHANICAL ENGINEER
LQ.2 5 1,0 AUG 3 1 0 p - '7.00N Q