HomeMy Public PortalAbout10040 OLIVE ST_Sewer__ w - - c-
6A 642D - CE808 - 9i73 APPLICATION F R PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS T J I LOCALITYNEAREST
FOR APPLICANT TO FILL IN ROSS ST.LEGADESCRIPTION LOT NO. "t� OWNER
_ MAIL
BLOCK TRACT � � ADDRESS `
NO. OF BLDGS. _
SIZE OF LOT NOW ON LOT CITY '�`� TEL. NO.
USE OF —�
BUILDINGS +`'T - _ DISTRICTNO. GROUP MAP „_.--p)OCESSEO BY
PS i�``I
CONTRACTOR 'L >J"�f+''✓,tyJ J .�, # �'�`� �•
ADDRESS � 70� /' CONNECTION DATA
CITY STATION j 4„'• & DEPTH / -
J' ss” UPPER
STATE ? p+;y''' LIC -- MANHOLE REFERENCE P _O
LICENSE NO, ;A ._<:,� �%.. .__C.LA66 � �'y'�- ,poi 4 ✓L3
N kEdMiR-
O. DESC TYPE
PTION OF WORK FEE - —OF CONNECTION -LENGTH FROM
d HOUSE SEWER CONNECTING TO f Y. CURB P L'*.._ LENGTH M.L.70 P.L.
i PUBLIC SEWER 111 $7,00 • �:,
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD f10.00 CO. IMP. . JOB NO-
NO SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX7N.,CESSPOOL.DRV WELL, S5.00 C-D.
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING [`+
SEWER OR DISPOSAL SYSTEM a .$3.00 O
STATE ENCROACHMENT
MANHOLE_`--__-'_ ---` ! $7.00 PERMIT NO. W
- INDUSTRIAL c-
WASTE APPROVAL C/)
_ Z
OWNER'S PERMIT s 3 00 ----
GNARGES
AUTHORIZATION TOTAL. FEE I /c~'' — CONNECTION CHARGE FEE —
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN•NAMEO CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E ISTING DWELLING -
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF —19—
OWNER
9_OWNER OR NEW HOUSE SEWER •'Z P fi „tut t rF ;�,'
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS. APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD _ -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING �-I
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL IJ
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I
CA_iFCd?N to OR THATt�7�yEee.AL OWNER 0F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABORESID,ENTIA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE "1'f" q BACKFILL.S - k OF PERMITTEE
-"- - "— - CESSPOOLS
VALIDATION CK. M.0.
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