HomeMy Public PortalAbout9716 OLIVE ST_Sewer__ '6A 642'D'- CE808 8/73 APPLICATION FOR PERMIT
COUNTY OF LOS,r>t*1GELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 1
ADDRESS
LOCALITY ✓ � � (,./ I'
FOR APPLICANT TO FILL IN CROSSSST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL B
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BLOCK TRACT ! i Ir ADDRESS
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.SIZE OF LOT NOW ON LOTS CITY T T.L.
USE OF — _ ._— — D(STRICTNOGROUP MAP PROCESSED BY
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BUILDIN /tt^�
EONTRACTO N "SAa J4a' jL.6A/
ADDRESS 1-2— L /J}" CONNECTION DATA
..m STATION DEPTH
CITY �Lr'°� % Y^ TEL. NO.-2,65-31�
STATE- •'fI' J ""'7 LIC P� MANHOLE REFERENCE UPPER
LICENSE NO;_ 1.-+{ ` Com/ GLASS LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR --
PITS AND/OR DRAINFIELD $IO.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 -
CONNECT ADDITIONAL BLDG.OR — AFFIDAVIT I WAIVES I EASEMENT RECORD.INSTR.NO. DATE
P! WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD _ O
EXTN„CESSPOOL.DRYWELL. $5.00 U
ALTER.REPAIR OR ABANDON HOUSE
-- HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM ® $3.00_ _ STATE ENCROACHMENT O
MANHOLE PERMIT NO, (~may
$7.00 - LLJ
----- - INDUSTRIAL u p.
sit WASTE APPROVAL
4•� CHARGES
OWNER'S PERMIT s -
AUTHOMAnCIN I TOTAL FEE CONNECTION CHARGE FEE _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /y -
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S.SIGNATURE
SIGNED THIS DAY OF 19— --
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK -
ADDRESS - SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LO ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCaRN IA OR THAT 1 AM THE EGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN�ABO DESCEDRE5IDENTIAL PROPERTY. ABANDON HOU5E SEWERSIGNT4IR � BACKFILL SEPTIC TANKS Cl
OF PEQM
- — SEEP.PITS) Cl CESSPOOLS.❑
VALIDATION CK. M.0. ( CASH
1
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