HomeMy Public PortalAbout5837-5837 1/2 OAK AVE_Sewer__ w
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7APPLICATION FOR PER IT
78A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Eng�neer ADDRESS
WUMAM A JENSEN Sup t of Sul cLg
LOCALITY /
NEAREST
FOR APP ANT O FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO ^ OWNER
MAIL
BLOCK TRACT ADDRESS E�o
NO 6F SLOGS
SIZE OF LOT 02 NOW ON LOT CITY TEL NO
USE OF
BUILDINGS OG 1 DISTRICT NO GRBK MAP PG ROCESSED BY 00,
CONTRACT 1/'� ✓ -!
ADDRESS CONNECTION DATA
CITY TEL STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM 0
HOUSE SEWER CONNECTING TO Y CURB PL M L TO P L V
PUBLIC SEWER ! SS 00
C NO
SEPTIC TANK SEEPAGE PIT OR J p�
PITS AND/OR DRAINFIELD 0 $1000 CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 0 $300
CONNECT ADDITIONAL BLDG OR �yy� AFFIDAVIT WAIY[N 11ASENINT RECORD INSTR NO DATE 0`
WORK TO HOUSE SEWER ! $300 V V h
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE! $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 53 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
TE AP ROV L
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE /}q1 CONNE TION E CHA FEE
I
HAVE AT THIS DATE A CONTRACT WITH THE HE N NAMED VCON REIMBURSEMENT FEE
HAVE
TO CONNECT THE ABOVE DESCRIBED STING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECT,", SIGNATURE
SIGNED THIS OF 19_
OWNER OR - NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK y ! �
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS R GULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTOIFYAT 1AM PROPERLY REGISTE D AND/OR ALTER REPAIR SEWER OR
LICENSED AS REY LOS ANGLES COUNTY A STATE OFSEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TTHE LEGANER F A INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ASCRIBED R ENT P PERTY ABANDON HOUSE SEWER
SIGNATURE / FILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) [ICESSPOOLS ❑
t1--_yALIDATI0N ROBERT A WOOD
• cK M o cpsH SUPERVISING MECHANICAL ENGINEER
0 1-5 0Q SEP 13 1 0 0 5.00- vz