HomeMy Public PortalAbout9402 LIVE OAK AVE_Sewer__ 64 2D 5-65
76AAPPLIC T16N FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 71UJOAN A LAN1131ECounty EngineerCOLEMAN W JENKHM Supt of Building FOR APPLICANT TO FILL IN LEGAL
DESCRIPTION LOT NO L
MAIL
BLOCK 02 n TRACT oL-,�'� ADDRESS
N F BLDGS _
SIZE LOT OW ON LOT CITY TEL NO
USE OF
BUILDINGS ,DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS S! �, Q _ CO ECTION DATA
CITY �(r TEL NO ZC�V STATION P_L / y DEPTH
LICENSE / 0 "� LICENSE MANHOLEREFERENCE „j PE
NO f/ CLASS
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
` HOUSE SEWER CONNECTING TO Y URB P L -L TO PL
PUBLIC SEWER @ $ 5 00
PTI TANK, SEEPAGE PIT OR PC NO d
PITS AND/OR DRAINFIELD @ $I O 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM C'' $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIY[R [ASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $ 3 00 0
R AB ND N HOUSE V
SEWER OR DISPOSAL SYSTEM C $ 3 00 NJ
HWY OR ST WIDENING d
EXTN ,CESSPOOL, MANHOLE $ 5 00 STATE ENCROACHMENT
PERCOLATION TEST $ 5 OG PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z Oo
L CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL 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 SEW R, APPROVALS DATE I NSPEC4 5 SIGNATURE
SIGNED THIS y DA]f1 1
OWNER OR - fit, xq�dJJ 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 ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
E ❑
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED 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 THEABOV SCRIBED RESIDENTIAL P OPE RTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS /
VALIDATION V
CK M O CASH
LACo? 2 3 4`0 FEB 20 1 a D 7.00- a