HomeMy Public PortalAbout9439 LEMON AVE_Sewer__ 6A642D FOR PERMIT
10-63
76A64APPLICATION � me
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSALl
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 4NEAREST
UILDING
JOHN A. LAMBIE, County Engineer DDRESS
WILLIAM A. JENSEN, Supt of Building
OCA L'TY
FOR APPLICANT TO FILL RD55 STLEGAL
DESCRIPTION LOT NOWNER 6
MAIL
BLOCK TRACT ADDRESS
l O OF BLDGS
SIZE OF LOT ' OO NOW ON LOT CITY TEL NO
USE OF P
DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
CONTRACTOR /( 0�O9/
ADDRESS ;7pjn IVCONNECTION DATA /
a' L STATION /O T DEPTH
CITY �;r/{/T/ TEL NO !J Cl
V v 5
COUNTY MANHOLE REFERENCE 11C) / LOWER
REGISTRATION NO ll
NO DESCRIPTION OF WORK FEE TYPE OFTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 a"
SEPTIC TANK,SEEPAGE PIT OR PC NO O
PITS AND/OR DRAINFIELD � $1000 CO IMP NO JOB NO V
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO cm
PRIVATE DISPOSAL SYSTEM @ $3 00 ^
CONNECT ADDITIONAL BLDG OR DO AFFIDA T WAIVER EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $3 00 9� /0!7�/�
OVERFLOW SEEPAGE PIT,DRAINFIELD / b
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 H-
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING LL
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT !T YY' L—
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i 00 CHARGES
OA CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COIIN._ REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER ,)
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
1 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 COON STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT i AM THE LEGAL OWN F, AND I END TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESC D IAL PROPE TV ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT E SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK m o CASH SUPERVISING MECHANICAL ENGINEER
�����4 678, OCT 8 1 0 D 5.00-
a