HomeMy Public PortalAbout9417 LONGDEN AVE_Sewer__ 3-E4
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APPLICATION FOR PERMIT �}
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING // T`J
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building _
LOCALITY
cROSSSST.
FOR APPLICANT TO FILL IN
LEGAL __ �
DESCRIPTION LOT NO. ,
i('/L`flJ OWNER
y� MAIL _
BLOC( ,� TRA. /!/"] _69 32 _ ADDRESS
--�/--- - —�-ICS NO. OF HLDGS. "rtea�
SIZE OF LOT NOW ON LOT CITY TEL. NO.
O
USE F -"-- --- _-
USE
NGS _ DISTRICT NO. GROUP MAP PROCESSED BY
BUIHK PG
CONTRACTOR
ADDRESS ��f^ /J �1 CONNECTION DATA
CITY (,-"j"��j//'�"(�-'/- J� .6�. NO /J f4' STATION f_ DEPTH
STATE UPPER
REGISTRATION NO. ! 7 / r_ COUNTY MANHOLE REFERENCE U .
NO. DESCRIPTION OF_WORK FEE_ TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO ��stii� Y. =CURB P.L. M-L.70 P. S -)-
PUBLIC SEWER $5_00 ^�''' —
i-i P.C.NO. y.
SEPTIC TANK,SEEPAGE PIT OR ^d ' f JOB NO, IL
PITS AND;OR DRAINFIELD @ $10.00 � CO.IMP NO. r 3r.
HOUSE SEWER CONNECTING TO ^' %. o
PRIVATE DISPOSALSYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. I
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1Y[R EASEMENT RECORD.INSTR,NO. DATE o
WORK TO HOUSE SEWER a $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING LLU
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO, Z
INDUSTRIAL
WASTE APPROVAL
i� CHARGES -
OWNERS PERMIT $ 21 00 -
AUTHORIZATION[TOTAL FEE L .- CONNECTION CHARGE 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 SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT -`""--"----�-
CONNECT ADDITIONAL
ADDRESS_ BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SELD T(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
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 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND i
RESIDE IN, THE ASOVZ'IESCRIBED RESIDENTIAL PR RTY.
ABANDON HOUSE SEWER
SIGNATURE a
OF PERMITTEE, yam-+' BACKFILL SEPTIC TANKS ❑ ,p y ¢
SEEP,PIT(5) ❑ CESSPOOLS ❑wommmammommil
3
VALIDATIONROBERT A. WOOD
I - SUPERVISING MECHANICAL ENGINEER
CK. M.O. ),CASH - 7.0