HomeMy Public PortalAbout9432 LEMON AVE_Sewer__ c ,,°-69
76A642D APPLICATION FOR P RMIT
76A64
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS C a
WILLIAM A. JENSEN, Supt of Buildmg ? �
LOCALITY l(
NEAREST
FOR AP LI A T CROSS ST
LEGAL
DESCRIPTIO O O OWNER
MAIL 21 42 le
BLOCK TRACT a ADDRESS
_ NO OF BLDGS
SIZE OF LOT _ NOW ON LOT CITY TEL NO
USE OF DISTRICT NO 1 GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRACTOR ✓! V s
ADDRESS CONNECTIO DATA
CITY TEL NO STATION DEPTH
I}�{I STATE ) J UPPER
MANHOLE REFERENCE
REGISTRATION NO �I COUNTY /
NO DESCRIPTION OF WORK FEE YPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP IL
PUBLIC SEWER @ SS 00
CL
SEPTIC TANK,SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ $10 00
CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVII 1AS[XENT RECORD INSTR NO DATE G
WORK TO HOUSE SEWER (9 S300
OVERFLOW SEEPAGE PIT,DRAINFIELD 131-
EXTN CESSPOOL,DRYWELL MANHOLE @ $5 00 d
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 Oo
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE / }
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 INSPECTOR S SIGNA RE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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 ❑
IS CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REOUIRED 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 ABOVE DESCRI D RESIDENTIAL PERTY ABANDON HOUSE SEWER
SIGNATURE 1 BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PITS) ❑ CESSPOOLS ❑
V ATIO1 ROBERT WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
L AI'o 7 7 4 5 -0 A?R 16 1 0 D 7.0 0-
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