HomeMy Public PortalAbout9507 OLEMA ST_Sewer__ 491
66642D 3-64
76A64APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE D1SP SAL
DEPARTMENT OF COUNTY ENGINEER Y
BUILDING AND SAFETY Engine BUILDING
Engineer
JOHN A. LAMBIE, County er
ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY_-
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. - -
LEGAL
DESCRIPTION LOT NO �.�, OWNER
,
MAIL -----�
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOTjj. AA
Y TEL. NO.
USE OF ^^
BUILDINGS STRICT NO. OUP MAP PROCESSED BY
BK PG
CONTRACTOR ADDRE5CONNECTICIT - TEL. NO. ATION f- !' .. DEPTHNHOLE REFERENCE _ UPPER
REGISTRATION NO. �'` - C ; LNO. GESCRIPTIONOE_WORK FEE - TYPEOF CONNECTION LENGTH FROM ivHOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P,L.
PUBLICSEWER $5.00SEPTIC TANK,SEEPAGE PIT OR . IMP.NO. j ��, JOB NO, fl.
PITS AND/
OR DRAINFIELD 0 $10.00 _. LU"._t __�--.� _..,..�
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO. V
PRA
IVATE DISPOSL SYSTEM 0 $3.00
CONNECT ADD!T1 ONAL BLDG.OR __ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN.,r_ESSPOOL,DRYWELL,MANHOLE 0 $5.00 HWY.OR ST.WIDENING � w
ALTER,REPAIR OR ABANDON HOUSE Y D.
SEWER OR.DISFOSAL SYSTEM $3.00 STATE EN
NCROACHMET
_ _-_ i PERMIT NO.
-q- --- ----r------ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $; 21 00 — --
AUTHORIZATION TOTAL FEE { CON NEC710N CHARGE FEE-- —^-
'I HAVEAT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - -'---
TO THE PUBLIC SEWER. APPROVALS DATE I NSPECTQR'S SIGNATURE
SIGNED THIS-_ Y OF _.19_ ---
OWNER OR '�� NEW HOUSE SEWER
OWNERS AGENT_,_ CONNECT ADDITIONAL -
BUILDING.OR WORK
ADDRESS— _ ------
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE .5 CORRECT AND AGREE TO COMPLY ----_— --.__--
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM GING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERS ND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY A STA E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER A tNTE D TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV D S IS 51 TI L R 'Y. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITT _ - SEEP,PITS) [� CESSPOOLS
OL
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
!°CK.r M.O. CASH