HomeMy Public PortalAbout9164 LONGDEN AVE_Sewer__ J.
E&063-69
6A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y
ADDRESS IBY
TOHN A, LAMBIE, County Ea Issas WILLIAM A. JENSEN, Supt aI Building LOCALITYNEAREST
FOR APPLICANT TO FIM IN cRos$ sT.
LEGAL
DESCRIPTION LOT NO OWNER+ MAIL 7BLOCK TRAGT - - , ADSS$IO, F SLOGS.SIZE OF _BUILDINGST NOW ON LOT 1D,ISTRICT NO. GROUP ' T1AAP 0PR9CEUSEOF
CONTRACTOR,," , � ✓ j3y � > P6
s ADDRESSCONNECTION DATACITC - ELNDSTATION ' 1 DEPTHz'STAMANHOLE REFERENCEREGISTRATION NO fG, " COU ;, :. LOWER
NO, DESCRf IO 0) R FEEHOUSE SEWER CONNECTINS; TOPUBLIC SEWER @ $3.00 TYPE OF CONNECTI01(� ti LENGTH FROM
SEPTIC TANK,SEEPAGE PIT ORPITS AND/OR DRAINFIELD @ $3_00 . CURB P.L.i M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD >_
EXTN.,CESSPOOL.DRYWELL @ $2.00 d
HOUSES EWER CONNECTING TO ✓ P.C,NO. O
PRIVATE DISPOSAL SYSTEM @ SLOp CO.IMP. N0. :' ! 90H N0. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0, ROAD PERMIT N0. d°
WORK TO HOUSE SEWER a 51.00 O
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM C+� $1.00 PERMIT NO, U
INDUSTRIAL Wd
WASTE APPROVAL 4n
CHARGES z
OV mws PERMIT 5 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 47; "�� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE hNSPECTOR'S SIGMATUR€
TO THE PUBLIC SEWER. ,, —F
SIGNED THIS pdy OR 19 NEW HOUSE SEWER d�_
OWNERS AGENT - CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
AND/OR DRAINFIELD
I HEREBY CKNOWLEDGE THAT I HAVEXEAD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL CJ DRYWELL
WITH ALL COUNTY ORDINANCE'S AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY L05 ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA 0R T T I AM THE LEGAL OWNER.OF THE ABOVE BACKFILL SEPTIC TANKS []
DESCRIBED RESIDE IAL PRO ERT AV SEEP.PIT(S I CESSPOOLS
SIGNATURE J G'
OF PERMITTE - •K:y,.,._.._._..
V'A MATd ROBERT A. WOOD
CK. Y.0.
SUPERVISING MECHANICAL,ENGINEER
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