HomeMy Public PortalAbout9458 LEMON AVE_Sewer__ D
CES08 ' APPLICATION FOR PER
canoe a-sa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVIBUILDING
FSIONDDRESS
IOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN. Supt of Building LOCALITY
FBLOCNEAREST 011.2 9
FOR APPLICANT TO FILL IN CROSS ST.
K
i /
LOT N0. Q OF � OWNER
MAIL _
TRACT_S1 t;AGp, ADDRESS
NO OF BLDGS.
ZQ NOWONLOT CITY TEL NO.
— IP ��
DISTRICT NO. GROUP MAP PROCES ED BY
CONTRACTOR BK PG_
ADDRESS YU CONNECTION DATA
CITY TEL.NO. STATION O DEPTH
REGISTRATION NO.
�a�+ ® COUNTY MANHOLE REFERENCEP
FrR
AP
NO. 1 DESCRIPTION OF WORK FEE
i HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CU P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 /
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P CAD.
PRIVATE DISPOSAL SYSTEM @ $1.00 /21 P. N0. JOB NO.
WORK TO
CONNECT
HOUSE ISEWERNAL BLDG.OR @ $1 00 TRUNK PERMIT N0. ROAD PERMIT N0.151 �e7/t7/7
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERNIIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Z 1 0-0 REIMBURSEMENT FEE
N�MED CON-
TRACTOR TO CIONNE T THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE IING DWELLING APPROVALS (/DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE IAL PROPRTY. BACKFILLSEPTIC TANKS ❑
SIGNATURE L SEEP.PITS ❑ CESSPOOLS ❑ '
OF PERMITTE
Or /-� jALIROBERT WOOD
M..0o.. CASH SUPERVISING MECHANICAL ENGINEER
45617.00
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