HomeMy Public PortalAbout9616 LONGDEN AVE_Sewer__ B08
E8ase APPLICATIONF PER, IT �y
aoe e
COUNTY OF LOS ANGELES SEWER—SEWAGE D1SP0�AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAI'/ffTIE, County Engineer
CASSATT D. GRIFFIN. Sup't of Building LOCALITY
_
14EARE:ST ----- -
F0 KPPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO ' OWNER
BLOCK TRACT - - -- MAIL ..
ADDRESS
NO.OF BLDG5,
SCZE OF LOT NOW ON LCT CITY TEL..NO,
U.SE OF --�
BUILDINGS ,__�...._._ _..� 1 DISTRICT N0, GROUP�. MAP PROCESSED BY
I:KPG � f'✓
CONTRACTOR
ADDRESS . CONNECTION"DATA
CITY T_i_.N0, STATION DEPTH
STATE MANHOLE REFERENCE - "RAPE✓- -
REGISsRATIONNO l� COUNTY
Nt�. �DE5CPJPT10N OF WORK FEE
HOUSE SEWER
CONNECTING TO
PUBLIC 5 W ER $3.00 TYPE O ®#RECT;ON LFTtC7H FROM
TANK,SEEPAGE FIT OR
PITS A Y.
PITS NJ/05 DRAINFIELD Cal s3,pp CURB P.L. NI i-TO P L.
OVFRFL.ONI 5€_,_CAGE PPT,DRAINFIFLD
EXT N..CESSPOOL.DhY`WELL @ $2.Q0_..��_---- — — -
HOJUSE SEWER CONNECTING TO * P C,NO,
PRIVATE DISPOSAL.SYSTEM @ $1.00--- CO.IMP, NO. - � --- JOB NO,
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER 51.00 _
ALTER, REPAIR OR ABANDONN HOUSE --STATE ENCROACHMENT -
SE`NEP OR DISPOSAL SYSTEM @ $1,00 PERMIT NO, 3
INDUSTRIAL -. .
- -- - WASTE APPROVAL
CHARGES
OVINERIS PERMIT q 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE i ;` REIMPURSETIENT FEE
I HAVE AT THIS DArF F CONTRACT WIT'Y THE HEREIN NAMED COPi-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE fNSP.t':CTOR`S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS I7A91 NEW HOUSE SE��tER ) "
-:�...
OWNER CONNECT ADDiT10FdAL
OVIN£RS AGENT---e` . _� " �._ _BUILDING OR VIPRIi. .�._--.� ----
:ADDRESS� SEPTIC TANK,SEEP.-P.IT(S)
._._____�___.�..�r.-��' ----. —.• ` ,. AND/OR
_ DRAiNFIELD
I IHEREBY' ACKNOWLC'D E THAT I HAVE READ THIS APPLICATION i
AND. STATE TrIA tiE :ABOVE_` 15 CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWEL.L El
WITH ALL COUN Y ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAG DIS PLSGSYS s - -
LICENSED AS PEQUIRED BY LOS ANGELES COUNTY AND TATE OF DISCONNECT
HOUSE SEWER I
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE -- -
DESCRIBED RES DIe TIAL PROPERTY. BACKI i. SEPTIC TANKS El
SIGNATURE -
SEEP. PJS{ ❑ CESSPOOLS
— �...�
OF PERMITTEE
)F --VAIMATTON ROBERT A. WOOD
CII. X.0. C31 H SUPERVISING hIIECNANICAL ENGXNEER