HomeMy Public PortalAbout9652 LEMON AVE_Sewer__ ,D_62
76AG42 D APPLICATION FOR PERMIT
78A 84
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engeer ADDRESS
in
WILLIAM A. JENSEN, Sup'1 of Building L
LOCALITY
NEAREST
FOR A P�.IC FILL t CR05S ST
LEGAL (ir ,r
DESCRIPTION LOT NO ,� •i OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS �
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS .� DISTRICT NO GROUP MAP CESSED BY
{. BK PG
CONTRACTOR
444 4
ADDRESS —,� ' CONNECTION DATA .� yJJJJ
C (' STATION DEPTH
dTEL NO f�
CITY [� I / STATE
T j H COUNTY MANHOLE REFERENCE /
REGISTRATION NO v
ND DESCRIPTION OF WORK FEE TYPE OF COION LENGTH FROM d
HOUSE SEWER CONNECTING TO Y URBJ P L M L TO PL
O
PUBLIC SEWER @ E5 00 (�[J _
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO ~'� JOB NO
PITS AND/OR DRAINFIELD @ E10 00 ix
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ S3 00 99 R
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE W
WORK TO HOUSE SEWER $300 a
OVERFLOW SEEPAGE PIT,DRAINFIELD H
EXTN,CESSPOOL,DRYWELL MANHOLE @ $500 Z
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER ORDISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT t 00 2
AUTHORIZATION TOTAL FEE nCONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS ATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ( j`
OWNER OR NEW HOUSE SEWER
OWNERS AGENT v
CONNECT ADDITIONAL C--
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBYACKNOW LEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 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
LS
IFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
IDE IN, THE ABOVE D SIDENTIAL PROPERTY ABANDON HOUSE SEWER
NATUREBACKFILL SEPTIC TANKSF PERMITT SEEP,PIT(S) ❑ CESSPOOLS ❑
�yALID-ATION ROBERT A. WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
L, 0 9 2 7%a :-u,Y 21 1 0 o 7.0