HomeMy Public PortalAbout9512 LIVE OAK AVE_Sewer__ - r
Al 24650 INSEEERTS y^�
CESOS 6.60 APPLICATION-
®V B/�eA�®�T� FOR , ■ I�., x
•7SA642D /"t P LICA • I O
COUNTY OF LOS ANGELES SEWER-SELVAGE DISPOSAL -
D ARTMENT OF COUNTY ENGINEER
BUILDING
UIMBLDING AND SAFETY DIVISION ADDRESS ✓ �/ /
JOHN A. LAIE, County Engiaeer
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST -
OR APPLICANT TO FILL IN CRoss sr.
LEGAL OWNER '
DESCRIPTION V LOT NO _
BLOCK TRACT /.$?&WVV4V ,'r�J A DRESS
MAIL
NO OF BLDGS.
SIZE OF LOT NOW ON LOT JANHOLERE-FERENCE
ITY _ TEL NO _
USE OF STRICT NO GROUP MAP PROCESS D BY
BUILDINGS
PG
CONTRACT0 A I l,K,�
ADDRESS �" COhfNNECTION ATA
CITIjj EL NO TATION ///...,,, DEPTH
REGISTRATIONJIF NO. �'���� / C' f� UPPE
CND DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER - @ $3 00 TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR . CUR 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 1 :3 19 P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 'CO.IMP. NO JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT N0. ROAD PERMIT N P.
WORK TO HOUSE SEWER @ $1 00 O
V
AEW ETR R OR DISPOSAL SYSTEM R ABANDON HOUSE @ $1 00 STATE ENCROACHMENT - O,
PERMIT NO
INDUSTRIAL U
WASTE APPROVAL µt
CHARGES vat
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE leo REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREI AMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWE 1,q -,i 1
SIGNED THIS D Qf 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS AND/OR DRAINFIELD
I HER Y 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 ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND//
// e'
LICDISCONNECT PLUG AND
ENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER /`s Ir
CALIFORNIA OR THAT I AM THE LE ER OF THE ABOVE
DESCRIBED RESIDE A PROPERTY. BACKFILL SEPTIC TANKS ❑ A, q �*'
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS IO �J( _
OF PERMITTE
®r ALMATION ROBERT A. WOOD
M.0. CASH - SUPERVISING MECHANICAL ENGINEER
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