HomeMy Public PortalAbout9619-9621 LONGDEN AVE_Sewer__ -6°
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APPLICATION FOR PERMIT ,-
S& .3
-DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
ADDRESS t i y ^.... .=fd" 'rc_ i�[�:r�-•'tom:.
,JOHN A. LAMBIE, COUNTY ENGINEER ----- —K—t ---
'�v - CASSA'TT 0. GRIFFIN, SUPT OP-BUILVING LOCALITY
NEAREST
FOR APPLICANT TO FILL INCROSS ST. -
LEGAL
OWNER
DESCRIPTION LOT NO. - - -
- n NIAIL
TRAC, ` : ADDRESS
NO OF L CITY TEL NO.,
_SIZE OF LOT NOW GN LOi
--
USEOCNG5" ,.�-. '� �,..: t�. _.. --�--- DISTRICT NO. �. GROUP � MAP
_BU
BK
CONTRACTOR_ -----
CONNECTION DATA
ADDRESS ----- ---
, /' STATION �; - DEPTH
CITY `"`�r '` TEL.NO.
C— ✓ 'it e..r%!" -.: _.— --- -- - -- —
MANHOLE REFERENCE '`:LPPER
;..� _
❑ STATE
REGISTRATION NO, COUNTY
No. DESCRIPTION OF WORK FEE
------ ----- — ----- -------- - -TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLICSEWER @ $3.5o_L_
--...- ----- ----. --
SEPTICTANK,SEEPAGE PIT OR I I -
PITS AND;QR DP.AINFIELD (d' $3..0^ -_--
i OVERFLOW SEEPAGE PIT,DRA.INFIELD ( P C NO.
EXTN.,CESSP00L,DRYWELL.,MANH0LC Ca_' $2.001 CO. IMP NO, JOB NO.
HOUSE SEWER CONNECTING To
— _-i PRIVATE DISPOSAL SYSTEM (a� $I:00 TRUNK PERMIT NO _ ROAD PERMIT NO.,
p°CONNECT ADDITIONAL P,LDG.OR STATE ENCROACHMENT
,^" — -_ ---- --_
%I WORK TO HOUSE SEWER (n, I - "
$ .00 PERMIT NO.
! ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 1.004 , WASTE APPROVAL
CHARGES -
I CONNECTION CHARGE FEE
t)'6tVVNER°S PERMIT_ � ^I oo— - --------- — —--
REIMBURSEMENT FEE -
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS i DATE ii NDPFCTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SEWER, NEW HOUSE SEWER -
SIGNED THIS_—DAY 0 __ J9—_ CONNECT ADDITIONAL -_T.—
OWNER OR - BUILDING OR WORK -
OWNERS ACEFiT �) ✓'�� ',� :•;.j.t
--- _.
�`—"� �' M� ----- SEPTIC TANK,SEEP, PIT IS!
ADDRESS ANG/OR DRA1NFiCLD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLD !
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STA'T'E LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR - DISCONNECT PLUG AND
LI CE NSEll AS REQUIRED BY L05 ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT l AM THE LEGAL OWNER OF THE. ABOVE -- --- -t-- "—
DESCRIBED RESIDENTIAL. PRO BACKF LL SEP(T��I TANKS L]
SEEP.PIT(5) J CESSPOOLS
SIGNATURE l .✓ .OF
PERMITTEE
I j
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CIiIEF PL13G. INSPECTOR
CASH