HomeMy Public PortalAbout9511 LONGDEN AVE_Sewer__ 54603 52.54
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B&[•fiSAPPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SArM SEWER--SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angolesa BUILDING
r' M.J. FOX, COUNTY ENGINEER ADDRESS -
CASSATT 0. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR "PLICANT TO FILL IN NEAREST-
CROSS ST.
LEGAL .._.....�..- - --.._._.._... ....�._.��...Y.._....._..--_-_•---
DESCRIPTION - LOT NO.---- ------ OWNER
BLOCK TRACT MAIL
ADDRESS
NO. OF L'I,�f)CS _.�.�..._
SIZE_OF LOT._ ..NOW_OPS LOT..__._ - CITY 'TEL. NO.
USE OF -- -
BUILDINGS D ';TR.Iln NO. ( GROUP f
BK PG
CONTRACTOR -
ADDRESS -CONNECTION DATA
CITY - TEL. NO. STATION DEPTH
[1 STATE M ANtIOLE REFERENCE
REGISTRATION NO. COUNTY .
tit'eeEt - _ LOY'ER_
-------^`-.-----. ""- TYPE OF CONNECTION LENGTH FROM -
N0. I DESCRIPTION OF WORK FEE CURB , r�e. M.L.-10 P.L.
s I HOUSE S&TR CONNECTING TO ,a
PUBLIC SEWER _ (c _.$.__3.50 .�-
i HOUSE SEWER CONNECTING TO
�I PRIVAT_E D SPCSAL -------
CONNECT ADDITi^NAL BLDG. OR - -� .. CO. IMP. NO. - JOB. NO.
WORK TO HOUSE SEWER_
tea. ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO,
D15COI'W T AND AB,AN70N SEWER
rNDIOR DISPOSAL SYSTEM 1.00 f STATE ENCROACHMENT
----���_._------------'--- � ------ PERMIT N0.
I 5 DTIC TANn,SL'EPAGE PiT OR I _.._.__
PITS AND/011 DRAINFIELD _ 2.00
Ct55P00L DR YWELL ! iNDIJ STfiiAL -
�-^- WASTE APPROVAL
� -� - S
SPECIAL CONDITIONS ONLY 2.00 ICHARGES -
CONNECTION CHARGE FEE
OWNER'S PERMIT -
AUTHORIZATION TOTAL. FEE i.e -�- - REIMBURSEMENT FEE
'. HANE. THIS DATE. CONTRACTED WITH THE HEREIN NAMED CON- AI'PROVALa DATE I5?ECTJr'SSIiNATUR!:
TRACTOR 10 CONNECT -THE ABOVE DESCR EE.'D EXISTING CWELLING
70 THE PUBLIC 5E�;+/E:'E
NEW HOUSE SEWER
SIGNED
OWNER OR CONNECT ADDITIONAL
-BUILDING OR WORK_--- �-
SEPTIC TANK, SEEP,PIT(S)
_AND/OR DRAINFI_ELD
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL 0 DRYWILL 0
AND STATE 'SHAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY OP,DINANCES AND STATE LAWS REGULATING. ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND''OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE-LEGAL OWNER OF THE ABOVE _A.BANDON HOUSE SEWERDESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS(]
SEEP. PIT(S) CI CESSPOOLS L-1_
SIGNATURE -
CF PERMITTEE
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION
BY
DEPUTY -_. DEPUTY-
BY BY
OO DEPUTY DEPUTY