HomeMy Public PortalAbout9662 LIVE OAK AVE_Sewer__ &E-
5& 6663 3.55 APPLICATION FOR PERMIT
5 E-
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING !�/`
ADDRESS 1 L' -•l_ :i r,
WM. J. FOX, COUNTY ENGINEER
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST -
CROSS -`----'-
LEGAL
DESCRIPTION LOT NO. I OWNER
BLOCK TRACT MAIL
ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF -'<
'UI
LDIN !�� DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR ` 4 y:
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION ?" - t DEPTH -
' ❑ STATE MANHOLE REFERENCE / - �!" UPPER
REGISTRATION NO. ❑ COUNTY ') t 1 ` LOWER"
Ivo. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO _ - TYPE OF CONNECTION LENGTH FROM
@ ` Y. CURB elk". M.L.TO P.L.
PUBLIC SEWER $ 3.50
-
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR _ CO. IMP. NO. JOB N0.
_ WORK TO HOUSE SEWER 1.00 _ _
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
_
DISCONNECT AND ABANDON SEWER
STATEENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
�I SEPTIC TANK, SEEPAGE PIT OR - -- ---- --- - — -- --
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
-—--
PERMIT ----------
CONNECTION CHARGE FEE
OWNER'S � t oo
AUTHORIZATION I TOTAL FEE I
REIMBURSEMENT FEE
NAMED CON-
TRACTORTTOS CONNECT DATE O THE ABOVE DESCRIBED CTED WITH THE H EXISNINGA DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS f—DAY OF —19-- NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR
OWNERS AGENT BUILDING OR WORK
-
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE '• i --
am
'A:LL.i1,N1 .i. FOX.COUNTY ENGINEER VALIDATION R.A. WOOD, CHIEF PLBG. INSPECTOR
J