HomeMy Public PortalAbout9501 OLEMA ST_Sewer__ CE808 3-64
75A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY ?
NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL LOT NO.
DESCRIPTION
OWNER
MAIL
BLOCK TRACY ADDRESS
-----------
NO. OF BLDG
S.
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NO, GROUP MAP MAP P"CESSXD 183Y
PG
CONTRACTOR
ADDRESS r':A_ CONNECTION DATA
CITY STATION DEPTH
C
J'4 I TY G
C
STAY'0 N
PER
STATE MANHOLE REFERENCE
COUNTY
_UNTY
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE T P OF CONNECTION
TYPE OF CONNXCTION LENGTH JROM,—,,
HOUSE SEWER CONNECTING TO Y. _CVRB P.L. M.L.TO P,L.
PUBLIC SEWER $5.00 1
C 0
I , JOB NO.
SEPTIC TANK,SEEPAGE IT OR _;' >
IMP N
PITS AND/OR DRAINFIELO a $10.00 0
I CO,IMP, NO, 0
HOUSE SEWER CONNECTING TO I
PRIVATE DISPOSAL SYSTEM @ $3.00 i CITY
PERMIT NO. ROAD PERMIT NO,
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I wAivER I K ENT Ii_ECORD_'W4TR.NO. DATE 0&1
WORK TO HOUSE SEWER @ $3.00 0
OVERFLOW SEEPAGE PIT,OR AINFIELD
EXYN.,CES�!P0Oi,,_DRYN�fEt.L,MANHOLE $5.00 U
HWY. OR ST.WIDENING LLJ
ALTER,RE PAIR OR ABANDON HOUSE
0-
SEWER OR DISPOSAL SYSTEM $3,00 STATE ENCROACHMENT
(/)
PERMIT NO. z
INDUSTRIAL
T WASTE APPROVAL
CHARGES
OWNERS $It 00
ONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE C
*1 HAVE AT THIS DATE CONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE
TRACTOR TO
CONNECT THE BOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTO NATURE
SIGNED THIS D y __19—
OWNER OR NEW HOUSESEWER
OWNERS AGENT Z r CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS._ SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
APPLICATION AND/.OR DRAINFIELD
E r
AND STAY THAT THE ABOVE IS _0 RRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [I DRYWFLL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY L OS ANGLES COUNTY AN A OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM L AL OWNER OF AND T NO TO DISCONNECT PLUG AND
P
RESIDE IN, THE A;—,E 11 F L?%-1 T' ABANDON SEWER
E ER
SIGNATURE
0
F PERMITT BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) ❑
CESSPOOLS [31
;VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
M.O. CASH
7.1C)
6 2 9 y L)
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