HomeMy Public PortalAbout9429 LEMON AVE_Sewer__ 76AG42D CATION f \PO LI �'O R PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angele8. BUILDING
WM. J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL INNEAREST
• CROSS'ST,
LEGAL f
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR ♦ 4-
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
�ST6TE MANHOLE REFERENCE
REGISTRATION NO. �/ ❑ COUNTY- UPPER LOWER
L TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y CURB P L. M L TO P.L.
HOUSE SEWER CONNECTING TO �� �g,� � ,�3 �T
PUBLIC SEWER Q •$ 3.50 s�
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM - 1 00 -
CONNECT ADDITIONAL BLDG OR S CO. IMP. NO. JOB NO.
WORK TO HOUSE SEWER - 1 00 _
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO -
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY •2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 �00�
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
To
RT CCONNECT
THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS �DAfE INSPECTOR'S SIGNATURE /
NEW HOUSE SEWER
SIGNED THIS DAY OF _19-
OWNER
19 OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORKS O.1U, ,,'•.P �(
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[3AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR j
LICENSED AS REQUIRED BY LOS ANGE S OUNTD
Y AND STATE OF ABANDON HOUSE SEWER
DISCONNECT PLUG AN �r
CALIFORNIA OR THAT 1 AM THE LE L NER OF E ABOVE
•DESCRIBED RESIDENTI - BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OFPERMITTEE
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION
.� o 1 0 � JUL2 9 4 2b 0-
BY BY
DEPUTY ,per DEPUTY
BY BY �J� ^ /AA/_
��® DEPUTY (/�� / DEPUTY ,