HomeMy Public PortalAbout9016 RANCHO REAL RD_Sewer_1968-05-24 r
CE808 3-64
7f,A6�32U APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRCSS
LDING
JOHN A. LAMBIE, County Engineer - - — --- — - -- - — T
WILLIAM A. JENSEN, Sup't of Building
ALITYRESFOR APPLICANT TO FILL IN OSS ST - - -- - -- -
LEGAL
DESCRIPTION LOT NO. --_ y - OWNER_`_--- -.-_---*
- - _ MAIL
BLOCK TRACT ADDRESS
NO OF SL GS_ -- - -- -- i -
SIZE OF LOT NOW ON LOT CITY TEL- NO. _
USE OF _ TMANHOLE
ISTRICT NO. GROUP BK MAP PG PROCESSED BY
BUILDINGS
CONTRACTOR " CONNECTION DATAADDRESS d-. ' , � � .TATION DEPTH
CITY TEL. NO. _ -..—__-_ UPERANHOLE REFERENCEREGISTRATION NO. LOWER
__- ._____ __,\ LENGTH FROM
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION -HOUSE SEWER CONNECTING TO . CURB P L. M.L-TO P,L.
PUELIC SEWER 0 $5.00 --- - --P:C.NO. a
SEPTIC TANK,SEEPAGE PIT ORILPITS ANO/OR DRAINFIELD $10.00O.IMP_NO. _ .108 NO. _-_-
HOUSE SEWER CONNECTING TORUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 83.00
CONNECT ADp ITIONAL BLDGR VI
.OAFFIDA- T-T-wAIYER MENT RECORD,INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 ` T O
OVERFLOW SEEPAGE PIT,DRAINFIELD �__ EASE
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 yvt
ALTER REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 83.00 I STATE ENCROACHMENT
PERMIT NO. z
--------- ---- - INDUSTRIAL -- -
WASTE APPROVAL
CHARGES
OWNERS PERMIT $i 2j 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE -
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �-APPROVALS
TO THE PUBLIC SEWER. DATE INspm OR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK I
ADDRESS _ -- SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I 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 ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR I
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA. OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
R EST OF IN, THE ABOVE. DESCRIBED RESIDPROPERTY.ROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ ��.
-__ - ---- SEEP.PIT(S) ❑ CESSPOOLS
f.
VALIDATION. ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH