HomeMy Public PortalAbout10611 OLIVE ST_Sewer__ APPLICATION FOR FSRMIT
COUNTY OF LOS ANGELES SEWER--SELVAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING a e'
N '
JOHN A. LAMBFE, County Engineer ADDRESS
CASSAP'T D. GRIFFIN,Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. �
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT "'LA DIFSS
NO.OF BLDGS.
SI7_E OF LOT_ NOW ON LOT TEL.
US£OF
BUILDING!; `' ? DISTRICT NO. GROUP MAP ROCESSIlD BY
—� `" -- BK PCs
CONTRACTOR. -
ADDRESS ;ds' ° CONNECTION DATA
TEL.NO. ' �` STATION DEPTHS '
.,t..
ea g - ESTATE MANHOLE REFERENCE fi ri- UPPER',
REGISTRATION NO. h�i.. ,-J` ❑ COUNTY ; a LOWER
HOUSE
DESCRIPTION OF WORK FEE —
HOUSE SEWER CONNECTING TO
PUBLIC SEXIER @ $3.00 —
SEPTIC TANK, SEEPACE PIT OR TYPE OF CONNECTION. LENGTki FROM
PITS AF#D/OF.DRAINFIELD @ $5.00 Y. CURB < L,? M.L,TO P,L.
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOLDRYW£LL,!dANHOLE @ $2.00
HOUSE SEWER CONNECTING TO @@ P.C.NO.
PRLVATE DISPOSAL SYSTEM @ $1.00 CO.IMP,N0. y d P JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00 '"BUNK PERMIT N0. ROAD PERMIT N0.
@ _
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $9.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER`S PERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS ( DATE I INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. T -�—I—
SIGFIED THIS DAY OF NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT z � "�—4 _BUILDING OR WORK
SEPTIC TANK, SEEP,PIT(S)
ADDRESS --. _ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS .APPLICATION —
AND STATE THAT THE ABOVE I§ 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/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER ,4F THE ABOVE --
DESCRIBED RESIDENT a PROPER f p. BACKFILL SEPTIC TANKS❑
SIGNATURE
�� SEEP.PIT(S) ❑ CESSPOOLS
:y�- �',
OF PERMITTE "•
�F VALIDATION ROBERT A.WOOD
GSI ti.C. C"H SUPERVISING MECHANICAL ENGINEEtR