HomeMy Public PortalAbout5732 NOEL DR_Sewer__ 78A Q,42D - OEM - 9"3 APPLICATI N FOR ERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADORlSS 3 a E L -ben Vr---
LOCALITY 1 L G
8 /
FOR APPLICANT TO FILL IN
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DESCRIPTION LOT NO /(� ( � C OWNER / YIJ U IST
MAIL O W ,` I ,s li/
BLOCK TRACT ADDRESS p/1 W �(/� I'�NO /
SIZE OF LOT -NOW OON LOTS CITY �nC�' TEL NO AW404G
USE OP DISTRICT NO GROUP MAP fy�ESSED BY
BUILDINGS
CIJ �U I/_6-` w` .,og . . �-
ONTRACTO � l 1 � S�.�✓(G�
ADDRESS q--A (/1/B I f- CONNECTION DATA
CITY '� C1 EL NO ABS`3STATION DEPTH
STATE /_ C LIC AA UPPER
LICENS! NO �6,9- CLASS 3 i MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO CURB P L ML TOP L
UBLIC SEWER ® $7 00
SEPTIC TANK SEEPAGE PIT OR J C NO
PITS AND/OR DRAINFIELD $1000 CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $S 00
CONNECT ADDITIONAL BLDO OR AFFIDAVIT wuriE ■Ilasr�rT RECORD INBTR NO DATE
WAY HOUSE SEWER Q f8 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL O $S 00 HWY OR ST WIDENING UJ D
ALTER REPAIR OR ABANDON HOUSE Y O
SEWER OR DISPOSAL SYSTEM 411 $300 STATE ENCROACHMENT F�
MANHOLE ! $7 00 PERMIT NO W
INDUSTRIAL Q6.
WASTE APPROVAL CO2
O YYmm Q'7 $
CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE +
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AIOVAL�
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(8)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT! LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV! ESCRI ED RE81D IAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE �✓(/L/L/ BACKFILL SEPTICNKB
SEEP PITS) CE SP OLS
ell VALIDATION CK M 0 CASH
86 EP 2510 U 900 ®9b