HomeMy Public PortalAbout6012 OAK AVE_Sewer__ i
IIs 64z D 10 68 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGIIIEER
BUILDING AND SAFETY DWISION F.DORESS
G
JOHN A LAMM County En ser
WILLIAM A JENSEN Sup t of H1Bld)n9 p
Y
T
FOR APPLICANT TO FILL IN ST
EGAL
DESCRIPTION LOT NO , OWNER
MAIL
BLOCK TRACT / ADDRESS
/ NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP MAPP CESBED BY
BK PO
CONTRACTOR
ADDRESS GGG777 CONNECTIONV DATA
40,
3 STATION DEPTH
CITY TEL NO s�
—STATEMANHOLE REFERENCE UPPER
REGISTRATION NO LJ COUNTY92
WER
NO DESCRIPTION OF WORK FEETYPE OF S2ftNj&VON LBN TH FR /
HOUSE SEWER CONNECTING TO Y URB P L M L T
PUBLIC SEWER $3 00 P C NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD
$
10 00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ^
PRIVATE DISPOSAL SYSTEM $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT aAIYSS I SIISSNSNT RECORD INSTR NO DAT
WORK TO HOUSE SEWER SS 00
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE $3 00 H
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
OWNERS PERMIT
WASTE APPROVAL
CHARGES
s 2 00
AUTHORIZATION TOTAL FEE &V CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 8 SIGNATURE
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER ) 7_
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(6)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS RECULATINQ CESSPOOL [3DRYWELL [3PLUMBING AND SEWERS
1 HEREBY CERTIFY THAT 1 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 ABO E DESCRIBED RESIDENTAAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
BEEP PIT(S) ❑ CESSPOOLS
VALMATIROBERT A WOOD
CK M o c SUPERVISING MECHANICAL ENGINEER
699gis » 2 1 o e
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