HomeMy Public PortalAbout9430 LEMON AVE_Sewer__ i� G r
10-63
76A642D APPLICATION FOR P RMIT
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 o4 Building
LOCAL TY
NEAREST
FOR APPLIC T FII.L ; OF CROSS BT
LEGAL
DESCRIPTION LOTN _' OWNER
MAIL
BLOCK TRACT_ ` ��� ADDRESS A �M
NO OF BLD 5
SIZE OF LOT NOW ON LO7 CITY TEL NO
USE OF DISTRICT NO GROUP MAP PR SSED BY
BUILDINGS Xz.
BK//
CONTRACTOR •/(�� ��yL�� r j? `7, �
G
ADDRESS L,Cwp (/ CONNECTIO DATA
STATION .��J �7 DEPTH
CITY TEL NO 7 L `
ATE UPPER
REGISTRATION NO COUNTY MANHOLE REFERENCE l/:��
NO DESCRIPTION OF WORK FEE }YPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO / Y CURB P L ML TO P L
PUBLIC SEWER @ 35 00 Qom(,
SEPTIC TANK,SEEPAGE PIT OR P 1 NO O
PITS AND/OR DR INFIELD @ 510 00 CO IMP NO JOB NO J
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I CASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ 5500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER ORDISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE ER ,l APPROVALS TE INSPECTOR'S SIGNATUR
IE
SIGNED THIS DAY F Cx �_'�/ 19�aS
OWNER
OR �/ NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS "i 4 .� �"v�A 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 DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A E AESCRIBERESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
AROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
, 0568" 1510 D 7.00