HomeMy Public PortalAbout9606 LEMON AVE_Sewer__ 76A 6421D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 9646 Z. Lemon Ave.
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL O •
BLOCK TRACT ADDRESS
1816 Son Gabriel
NO. OF BL G5.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP0K PG PROCESSED BY
CONTRACTOR .
ADDRESS CONNECTION DATA
CITY ,�' ZO$IN1Y� TEL. NO. �1, STATION DEPTH f
STATE231 LIC '4.F7 MANHOLE REFERENCE UPPER
LICENSE NO. 'j' G
KLASS LOWER
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER a $17.00
P.C.NO.
SEPTIC LANK.SEEPAGE PIT OR CO. IMP.NO. JOB NO.
PITS AND/OR DRAINFIELD $10.00
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER [AS[N[MT RECORD. INSTR. NO. DATE (,)
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD WJ
EXTN..0 ES SPOOL.DRYWELL. $5.00 I,y
I ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING r
SEWER OR DISPOSAL SYSTEM 83.00 STATE ENCROACHMENT
MANHOLE PERMIT NO.
$7.00 INDUSTRIAL O
WASTE APPROVAL
OWNERSPERMIT E 00 CHARGES w
AUTHORIZATIONI TOTAL FEE CONNECTION CHARGE 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 SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
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
IHEREBY 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
CALIFC,RNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS 13SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK.. M.O. CASH
A �
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