HomeMy Public PortalAbout9091 LYLEDALE ST_Sewer__ i 7
E-6D
S& 63 12.54 ■APPLICATION- OR PERMIT
1 5 E•6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer N�
County of Los Angeles BUILDING �
WM. J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
- " I
FOR APPLICANT TO FILL IN CROSS ST. �
LEGAL
DESCRIPTION LOT NO. ` O `` � ? � OWNER
BLOCK TRACT ..a MAIL
ADDRESS
NO. OF GS.
SIZE OF LOT NOW ON OT CITY TEL. N0.
USE OF -194
BUILDINGS DISTRICT NO. GROUP MAP
EK
CONTRACTOR A/
ADDRESS �/ CONNECTION DATA
CITY EL. NO 0� _7Y STATION S DEPTH
REGISTRATION NO. ElCOUT TY o 6-111, FSMANtiO E�REFERENCE LOQ
"`:DTYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE ° Y CURB P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO .p�.1 -I" /Ztv'1'0
PUBLIC SEWER Q $ 3.50 P
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 d
CONNECT ADDITIONAL BLDG, OR CO. IMP. NO. JOB. N0.
WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER - STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR .I
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
S PECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S s t 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- c.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING a APPROVALS DATE IN� ECTORS SIGNATURE
TO THE PUBLIC 2SR
SIGNED THIS y 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
~ SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE T AT I HAVE READ T S PPLICATION CESSPOOL C3DRYWELL El
AND STATE THAT THE ABOVE IS CORRECT AND AGR TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE 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
LICENSED AS REQUIRED LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI PROP TY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE � n
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
' BY DEPUTY 4B� $ 9S nAY 25 4DEPUTY
50 In
BY BY DEPUTY 4*e