HomeMy Public PortalAbout6516 OAK AVE_Sewer__ r I
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8APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE. DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING f
ADDRESS_,
JOHN A. I.AiMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY_-
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. r_` - -,-
LEGAL
DESCRIPTION LOT NO,61OWNER 3 —E
BLOCK TMAIL
ADDRESS
r NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS iDISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTO
ADDRESS t� CONNECTION DATA
CITY �i' TEL.NO. r STATION DEPTH
jd19 STATE MANHOLE REFERENCE P I
-REGISTRATION-REGISTRATIONN_0.��� �,, c� � COUNTY b r LOWER,X
NO. DESCRIPTION'OF WORK FEE
HOUSE SEWER CONNECTING TO (+ _
PUBLIC SEWER C.) $3.00 I —y
SEPTI^TANK,SEEPAGE PIT OR -TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L, M.L.TO P.L.
PITS AND/OR DRAINF_IELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL. DRYtJELL @ $2.00
HOUSE SEWER CONNECTING TOa '7 _.}� P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. p' ;y q JOB NO.
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO, ROAD PERMIT NO.
WORK TO HOUSE SEWER C $9.00 ^ _4
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM C' $1.00 _PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERIMIT Z 00 CONNECTION CHARGE FEE
��'`
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR 'TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -- �—
SIGNED THIS DAY OF 99— NEW HOUSE SEWER
OWNER OR
CONNECT ADDITIONAL
OWNERS AGENT - SUILDINGORWORK
ADDRESS TSEPTIC TANK,SEEP.PIS)
' AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL_❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES. AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/Oft DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM )TE LEGAL OWNE'p--OF THE, ABOVE
DESCRIBED RESIDENTIAL PROPE T�1 --] J J� BACKFILL SEPTIC TANKS ❑
SIGNATURE f,%� f '�'.:. I, SEEP. IT(S) ❑ CESSPOOLS ❑
OF PERMITTE `` '
�g -VALIDATION ROBERT A. WOOD
j cX.'-` X.O. CASH SUPEI#V(SING MECHANICAL. ENGINEER
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