HomeMy Public PortalAbout9228 LONGDEN AVE_Sewer__ 6A 642D -CE808- 10-71 APPLI CATIO FOR Pi� M IT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING .+,,',[)^^jjam� l �r
ADDRESS L^V� _Y,�(4/.,^IYI.)�{C n' J .✓LOCALITY• I!1/TL 4 ` !
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FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
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DESCRIPTION LOT NO. '�- / OWNER wryy
MAIL
,7L- TRACT 137 ADDRESS y x
BLOCK 44
NO. OF SLOGS. L,
SIZE OF LOT NOW ON LOT CITY r TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP CESSE6BY
BK PG
CONTRACTOR
ADDRESS " CONNECTION DATA//,�61��
CITY TEL, NO. STATION ; DEPTH ,
STATE LIC MANHOLE REFERENCE "" lC=�/�T r UPPER
LICENSE NO: CLASS __
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ,_y + LENGTH FROM
HOUSE SEWER CONNECTING TO �7� Y. CURB .L: M.L.TO P.L.
PUBLIC SEWER 0 $7.00 �y� LO P.C.NO.
SEPTIC SANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO,
PITS"AND/OR DRAINFIELD � $10.00 }
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (1
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIYEE I EASEMENT jfRECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD _ECSo
XTN., ESPOOL,DRYWELL. @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00SENCROACHL
TATE MENT
MANHOLE ! $7.00 PERMIT NO. D.
INDUSTRIAL N
WASTE APPROVAL
�,- CHARGES
OWNERS PERMIT s -
AUTHORIZATION I TOTAL FEE j ) CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENTFEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
70 THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER F�
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS_
SEPTIC TANK.SEEP,PIT($)
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ry
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL L1
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
CALIFORNIA OR THAT I M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE ESCRIBED RES�NTIAL TY. -ABANDON HOUSESEWER
SIGNATURE ` BACKFILL SEPTIC TANKS ❑
OF PER - -- SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION \ CK. M.O. CASH
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