HomeMy Public PortalAbout9422 LEMON AVE_Sewer__ 10-69
76A642D APPLICA /ION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LO � OWNER
MAIL
BLOCK TRACT I ADDRESS
tl NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR //14Z
ADDRESS ryCONNECTION DATA
CITY TEL NO STATION �9/ •� DEPTH
STATE UPPER
MANHOLE REFERENCE `
REGISTRATION NO 7 COUNTY
NO DESCRIPTION OF WOR FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P L M L TOP L
PUBLIC SEWER @ 35 0o PC NOO
SEPTIC TANK,SEEPAGE PIT OR CO IMP,NO JOB NO y V
PITS AND/OR DRAINFIELD @ 31000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ix
PRIVATE DISPOSAL SYSTEM @ S3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER [AS[M[NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD fL
EXTN CESSPOOL,DRYWELL,MA NH OLE @ 55 00 a
HWY OR ST WIDENING N
ALTER.REPAIR OR ABANDON HOUSE Z
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
EEI
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE �INS61PIECTO 'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER I
OWNERS AGENT
CONNECT ADDITIONAL f
ADDRESS BUILDING OR WORK
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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS P 05AL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE 11101m -1 SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK M o CASH SUPERVISING MECHANICAL ENGINEER
4535 JAN161 0 D '7.00- IT