HomeMy Public PortalAbout5744 OAK AVE_Sewer__ v
7CA 842D-CE808-10-71 APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE D SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [.0DRESS
UILDING S
OCALITYEARESTFOR APPLICANT TO FILL IN ROBB STT
LEGA 1
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
NO OF
SIZE OP LOT_OrlWNOW ON LOTS CITY TEL NO
USE OF � I_��
BUILDINGS u DISTRICTNO GRO BK MAP P' PROCESSED BY
CONTRACTOR D l..P /
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE LIC MANHOLE REFERE E UPPER
LICENSE NO CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECT LEND ROM
HOUSE SEWER CONNECTING TO Y CURB L O PL
PUBLIC SEWER ! $7 00 NO
SEPTIC TANK SEEPAGE PIT OR
PITSIMP NO JOB NO
PITS AND/OR DRAINFI ELD 81000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROA ERMIT NO d
PRIVATE DISPOSAL SYSTEM SS 00 O
CONNECT ADDITIONAL IMOMPBR AFFIDAVIT MAIYE■ SININT I RECORD INS NO DATE (�
WORK TO HOUSE SEWER $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 1-
SEWER OR DISPOSAL SYSTEM 8900 STATE ENCROACHMENT W
MANHOLE O $7 00 PERMIT NO N
INDUSTRIAL Z
��������++�� WASTE APPROVAL
OYY1\EEM PERMIT S 9 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I RHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FELE*Q
TACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 8 SIGNATURE
SIGNED THIS DAY F 19_
OWNER OR '� NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL 6
ADDRESS ��7� / O� I BUILDING OR WORKSEPT
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION / TANK BEEP PIT(8)
ANDO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1Y
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 AS DESCRIBE ES E PgPPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS [3OF PERMITTEE *� SEEP PIT(8) C DOLS
` VALIDATION �CKM O CASH
I�ulo
7 Cl 1 3;3
SEP 15- 1 0 D 6.00-