HomeMy Public PortalAbout9080-9082 LYLEDALE ST_Sewer__ ICE8o828.59 APPLICATION FOR PERMIT `
COUNTY OF LOS ANGVF.LES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY' ENGINEER
BUILDING AND SAFETY DIVISION BuILD ING
JOHN A. LAMBIE, County Engineer ADD
CASSATT D. GRIFFIN, Sup't of Building LOCALITY'"i �•t_ t
NEAREST
FOR APPLICANT TO FILL IN CROSS sr.
LEGAL
_ DESCRIPTION LOT NO ' OWNER
BLOCK - TRACT - _. r i, MAIL � y
ADDRESS
NO.OF
SIZE OF LO')rY73� :"_� NOW ON LOTS CITY ff TEL. N0.USE OF
BUILDINGS DISTRICT N0. GROUPBK I MAP I PROCESSED BY
r r PG
CONTRALTO
ADDRESS,rf f l.e ,. + * CONNECTION DATA
CITY ��, ''� TEL.NO. STATION DEPTH
(...W
;-STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. COUNTY
NO. DESCRIPTION OF WORK .FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 t-, TYPE OF CONNECTION LENGTH FROM ..
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $2.00 P.C.N0.
_ •a
HOUSE SEWER CONNECTING TO CO.IMP. N0. JOB No.
O.
_ PRIVATE DISPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
_ WORK TO HOUSE SEWER @ $1.00 - •.
SEWALTER OR DISPOSAL SYSTEM @ $1 00 EPAIR OR ABANDON HOUSE STATE ENCROACHMENT .-...-
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTIINGAMED DWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
LE
LUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
CENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
ALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS
k-CgIBED R$SIDENTIA1.4 PERTY - �' / ❑G-ryryyyA�'URF,� ti;' ``- i, �- ,1yJ µ4n Jr 'SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTTEE.
®F VALIDATION ROBERT A. WOOD
cK. Y.o. CASH SUPERVISING MECHANICAL ENGINEER