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HomeMy Public PortalAbout9658 LONGDEN AVE_Sewer__ FC.A6420 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING I NG E FADDR es JOHN A. LAMBIE, County Engineey z WILLIAIM A. JENSEN, Supt of Building L O_ OCAL-Y NEAREST ElEiT J CROSS 57. FOR APPLICANT TO FILL IN L D.SC !PT!ON LIT NO OWNER ,MAIL 13LQCl< I RACT ADDRESS ✓ Y7 NO. OF SLOGS, !,OT NOW ON LOT CITYI7TEL. NO. — JSE BC LL D NCS DISTRICT NO. GROUP MAP PG PROCESSED BY SK CONTRA(A DDRESS CONNECTION DATA A 5 iATI`QN DEPTH. TEL. NO. 13TATEMA NHO LE 4FrRFNCF LOW` Y REGV-TPATiONLOWER N 0: COUNTY NO DESCRIPTION OF WOPIC FEE TYPE OF LENGTH FROM E_S LW ER C-0 N NE'C;T­I N_GT_0___ HOUS Y. CURB P.L. TO P.L. PUBI-,C SEWER @ $5..00 EA - -------— P-C.NO. s I - JOB NO TS AND,OR DRAINFIELD @ SIO.00 :O�IMF.NO. 11()USE SEWER CONNECTING TRUNK PERMTT NO. ROAD PERMIT NO, FR ATE DISPOSAL SYSTEM @ $3.00 .0NNFCT ADDITIONAL BLDG—OR I AFFIDAVIT I WAIVER EASLMENT I RECORD IN,-, No. DATE RK 70 HOUSE SF"WER ca) $5: 00 ------------ 'q-CiESSPOOL,DRYWELI-.iAANHOLE(cb $5.00 ------- HWY.OP.ST.WIDENING ALT_ .ER,REPAIR OR ABANDON HOUSE Tcm C $3.00 Tr EN(_ROACHMENT PERMIT NO. )NDUSTRAL WASTE APPROVAL OVMER'S PERMITT ' CHARGES _p "V —--------- _-2f CONNECTION CHARGE',LE AUTHORIZATION TOTAL FEE 0 I HAVE AT THiS DATE A CONTRACT WITH 'THE: HEREIN NAMED CON* REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DVSCR IBED LXIST7NG DWEL 1_1 NG TO THE PUBLIC SEWER. APPROVALS DATE IN50ECTOR'5 SIGNATURE-- - SIGNEO TH)S _DAY OWNER C R NEW HOUSE SEWER OWNERS CONNECT ADDITIONAL ADDRESSt3 WILDING OR W RK _ 'SEPTiC fANK.SEEP,PIT(S) iHEREBY ACXNOINLEDGE THAT I HAVE READ THIS APPL!CATION AND/OR O­RAtNF1C.1_O AND .TAI THAI T�!E ABOVE IS CORRECT AND AGREE TO COMPLY J------- WIT H COUNTY Ai'I- ORDINANCES AND STATE LAWS REGULATING e�j B I CESSPOOL DRYWELL PLU jNG AND SEW r_R�. iHEREBY CFRTiFY THAT I AM PROPERLY REGISTERED AND/OR AL E",REPAIR,SEWER OR LICENSEDALAFORN AS REQUIRED 13Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I A OR THAT f AM THE LEGAL OWNER OP, AND INTEND TO PLUG AND RES!DE !N I HE ABOVE OFSCRt BED,RFSiDENTIAL PROPERTY- I. ABANDON HOUSE 5 EWER SIGNATURE. F PrRMITTEEBACKFILL SEPTIC TANKS ,_ SEEP.P11(S) ❑ CES5PO 6LS: 01 VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CN, M.O. CASH I V 'eA6420 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ALDRESSj JOHN A. LAMBIE, County Engineer L � ��— WILLIAM A. JENSEN, Supt of uilding LOCALITY NEAREST T. FOR APPLICANT TO FILL IN CROSS S ------LEGAL— DESCRIPTION LOT No.'�e t MAIL BLOCK TRAC-, ADDRESS NO L m SIZE OF LOT W DF ON �-OT CITY J v TEL, NO. E OF 131STRICT NO. GROUP I MAP PROCESSED BY e a Bez L ADDRE55 CONNECTION DATA STAT)bN DEPTH CIT;,CIT� TEL. NO. "CSTATE MANHOLE REFERENCE " REGI'STRAT'ION NO REGIS H COUNTY LOWER NO. CESC7 ION R!P OF' WORK FEETYPE OF CONNFCyH3N LENGTH VROM 9L HOUSE SEWER CONNECTING TO Y V F�fi �'PIL. M.L.TO P,L.,; 0 PU FSLIC SEWER @ S5.00 P.C'NO, -f SEF- -CP If c' -'i-J JOB NO. SEP-FICTANk , -PAG ,---R - AND/ORDRAINNELD @ $10.00 Co.IMP. NO, HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM $3.00 FFIDA AO -V-1 wm- -vfR ' F. I EASEMENT RECO 9N-STR. N 0. OAT VV}RK TO HOUSE SEWER 53 00 0 v F R---b Vv 5 c E FW&E 1;LT.ORA-[ N�f EL'D­ EXTN CESSPOOL,rRYWELL,MAN HOLE @ 5E.00 HWY. OR ST-WIDENING AL.ER,F`.F AIR OR ABAN©CIV HCU5E -fE --STA -NEROAr HMENT PERMIT No. INDUSTRIAL WASTE APPROVAL CHARGES OWNEWS PERMIT 2�7 00 CONNECTION CHARGE FEE AUTHORIZATION °TOTAL FEE I HAVE A?" THIS DATE: A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING MG-OWELL!� TO THE PUBLIC SlVE' ER- APPROVALS 1 DATE I P48PECTOP'S SIGNATURE. SIGNED THIS-,---DAY OF 0 W N F R OR NEW HOUSE SEWER. OWN ER.5 CONNECT ADDITIONAL -T BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) ISE H HF7FaY A(KNOWLEDGE THAT t HAVE READ THIS AFlPL!cAlTON AND/OR D­R.A[NFIELD t AND TATTA� THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING MIS CESSP PLU ING AND !:F%Y.F RS. OOL F L)RYWFLL I H REF.kY CERTIFY THA-t I AM PROPERLY REGISTERED AND;OR ALTER,REPAIR,SEWER OR Lt E CENSE AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL.SYSTEM CAL.1F D ORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLL AND RFSIE)E 'Vr DESCRIBED RESIDENTIAL PROPERTY- N HOUSE IN, THE ABC ABANDON E SEWER SIGN TURE OF'A BACKFILL SEPTIC TANKS L! -7-- SSEp.PIT(9I` CESSPOOLS /--VALIDATION ROBERT A. WOOD SUPERVISING MEC-HANICAL ENGINEER O. CASH