HomeMy Public PortalAbout6237 3/4 OAK AVE_Sewer__ /7
;E80810-83 APPLICATION FORF;tRMIT `
6A642. COUNTY.OF LOS ANGELES jZY,,jS
DEPARTMENT OF COUNTY ENGINEER 11
' - EWER-S\EWAGE DISPOSAL
4 ,
BUILDING AND SAFETY DIVISION —___ BIJ-I LO 1 N G, X
ADDRESS
JOHN A LAMBIE County Engineer
WILLIAM'A. JENSE�, Sup't of Building
LOCAL" Y
IR-1
NEARF
�47 ST
FOR APPLICANT TO, FILL IN CROIS ST.
LEGAL
,�ES ON OWNER
MAIL
BLOCK ADDRr5S
NO (FBL S
SIZE OF LOT NOW ON
LDGCITY TEL. NO.
OF R( P P OCESSED BY
USE
DISTRICT NO. G OUP MA
_a—LIDIN a B K PG
CONTRACTO
ADDRESS CONNECTION DATA
T TION DEPTH
ci .TEL, N i— A
STATE MANHOLE REFERENCE
Y LOWER
_REGISTRATION COUNT
N 0 EESC_kl 15—i_0N—0 R K E TYPE—OF CONNECTION _&T �R
Tj5 i 7 Y, CURB P.L. M.L_7 rPL.CYM
HOUSE SEW�.,CONNECTING
>
--l-tyaLIC SEW R F.C.NO. CL
9F JOB NO.
SEPTIC TANK, 7F:FA E R co•IMP. 1`40.
' PITS AND"OR DRAINF[ELD $1000
_ — --
i i-CUSE SEW__coKNEc-m0-
To TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
RECORD.
ADDITIONA. SLOG.IIXW F 6A—V R.N
IT
k
TO HOUSE SEW @ $3.00.
VOVFRFLOW SEEPAGE PIT,ORA!NFIELD
EY,TN GE SSROOL.DRYWELL,MANHOLE $5.00--
ALTER.RE AIR OR ABANDON HOUSE HWY.OR ST,WIDENING
F
SEWER<�RDISPOSAL SYSTEM $3.00
FA
PERMIT NO.
....... INDUSTRIAL
WASTE APPROVAL
I CHARGES
UT
OWNER'S PERMITmPERMIT $
�2�� 00
_1 CONNECTION CHARGE FEE
AHORIZATION 'AL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED REIMBURSEMENT FEE
TRACTOR T CONNECT THE ABOVE DESCRIBED EXISTING DWELLIN2 _T1;�Sn-_T-_r1 IGNATUR,E-
P 0 APPROVALS
TO THE USLIC SEWER. DATE
SIGNED THIS----T3yky OF
OR NEW HOUSE SEWER
OWNERS
CONNECT ADDITIONAL
SU i,LD!NG OR WORK I
f—
SEPTIC TANK,BEEP,PIT(6)
I HEREBY ACKNOWEDGE: THAT I HAVE L>
READ THIS APPLICATION AND/OR RAINFiELD
AND
4STATE THAT THSABOVE IS CORRECT AND AGREE 1*0 COMPLY
WiTH ALL COUNTY ORDINANCEG.�AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl rRYWELL 0
IHEREBY CFRT .THAT/V AM PROPERLY RE41STERIED AND/OR ALTER,REPAIR-SEWER OR
J_IC INSED AS REQU;4ED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL S,-STEM
,6F
CAL' ORNIA OR THATI AM THE I EGAL OWNrR OF AND.-INTEND TO FSI�NNEC-_- O
OPLUAND
RE SIDE IN, THE AOOVECR
,11K$ ISED ArRERTY.
St L ABANDON HOUSE SEWER
SIGNAl'URE
BACKFPILL_(S)TSFPTF_I,-
C.TCANKSF
S
S
ELS
OF PERMITTEE. SEEP, -1
OO
VALIDATION ROBERT A. WOOD
M.0CASH SUPERVISING MECHANICAL ENGINEER
.