HomeMy Public PortalAbout9550, 9548 LAS TUNAS DR_Sewer__ T
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76A642D APPLICATIO FOR PER T
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER A L
BUILDING AND SAFETY DIVISION -
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BUILD
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JOHN A. LAMBIE, County Engineer 6 L/ %.. /' V/►
WILLIAM A. JENSEN, Sup't of Building /
FOR APPLICANT TO FILL IN .
LEGAL ( 6
DESCRIPTION LOT NO. (,� OWNER
C MAIL
BLOCK TRACT �v ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF l
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
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B PG
CONTRACTO L-� D ✓ / L
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ADDRESS iZ t7 Q CONNECTION DATA
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CITY .TEL. NOa��/ STATION DEPTH
PRdTA MANHOLE REFERENCE �y UPPER
REGISTRATION NO. ��® ❑ COUNTY
NO. DESCRIPTION OF WORK FEE Ty OF CO NECTION LENGTH FROM
HOUSE SEWER CONNECTING TO _ I _/ CU B P,L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR O
CO.IMP. JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEE I EASEMENT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 d
ALTER.REPAIR OR ABANDON HOUSE
HWY. OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE O O�J CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPEC OR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT ,
CONNECT ADDITIONAL �
ADDRESS BUILDING OR WORK
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
I
CALFORNIA OR THAT I AM THE LEGAL OWNER Op. AND INTEND TO DISCONNECT PLUG AND
RES DE IN, THE ABOVE DESCRIBED RESIDENTIA PRERTY. ABANDON HOUSE SEWER
f
SIGNATURE ..
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ rf�
SEEP,PIT(S) ❑ CESSPOOLS
ALIDATION ROBERT A. WOOD
(`✓/
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
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