HomeMy Public PortalAbout9027 RANCHO REAL RD_Sewer_1961-05-04 � 7 d
24650 INSERTS
76A642.D60
APPLICATION FOR PERMIT .; '�. : .
COUNTY OF LOS ANGELES SEWER—"SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION auDRESSILD:NGS . IL
AD
TORN A. LAMBIE, County Engin®ar
WILLIAM A. JENSEN,Supt of Building LOCALITY TI~)1i 4 a t-F.
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
y _ Y OWNER
AL
DESCRIPTION L07 N0. �- C sal+ !,� + ' l '
BLOCK TRACT i q -- - MAIL -- _ ..7 tl y
S 4 �4.�°-- -ir-- -�-. ADDfiiESS 6 C Y: b. r .
NO.OF BbDGS.
No4,ON LOT CITY. TEL..N0. .
USE DI DISTRICT NO. GROUP MAP PfiACESSEA,B7
BUILDINGS I BK PG I J
CONTRACTOR !9� ° ! '•` I [ I"; 'Jf' I
ADDRESS sr� " ° ".ie - CO NVCTION DATA
CITY �vn f`TT t.N ' { STATION �," :_ C DEPTH
r STATE MANHOLE REFERENCE y W ✓ �-Uc.PP�ER
REGISTRATION NO. COUNTY
NO. DESCRtPT109 OF WORK FEE -
. II HOUSE SEWER CONNECTING_ TO = J�
J I PUBLIC SEWER (+0 $3.00 'd TYPE OF C*r gION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y. "CURB - P.L. M.L.TO P.L. y
ITS AND/OR DRAINFIELD C5 $3.00 ---' �- -
1 OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE.SEWER CONNECTING TO � � as� P.C.N0.
Yr2iiiiaiE GISFOS.AL SYSTEM ✓� $1.00 CO.IMP, NO. JOB NO.
CON FCT ADDITIONAL P.LDG.OR :�
WORK TO HOUSE SEWER @ $1,00 TRUNK PERMIT N0. ROAD PERMIT NO.�- U
AIT-:R,REPAIR OR A��4NDJN HOUSE STATE ENCROACHMENT
SEWER OP D.'SPUSAL SYSTeM @ $I.00 FERMIY NO. ca
INDUSTRIAL I"
WASTE APPROVAL W
CHARGES y
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE r4
AUTHORIZATION TOTAL FEE , � _1 " REIMBURSEMENT FEE
1 HAVE AT THIS DATE. A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGDWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAX OF 444A,r- 19,�/ NEW HOUSE SEWER i
OWN-ER OR �9 •r9 'i " 9 CONNECT ADDITIONAL -
OWNERS AGENTii �I4lr - °� ---� BUILDING OR WORK
ADDRESSE _L �"�& f "1L 1.ts--+-_.4 1} t� �, ... SEPTIC TANK,SEEP,PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGF. THAT I HAVE READ THIS APPLICATION AND STATE THAT THF ABOVE IS CORRLCT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL P�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT FLAG AND
LLICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE: OF ABANDON HOUSE SEWER
NIA OR THAT I AM 7.H F' LEGAL ,;6'FXNER OF',THE/ABOVE
ED RE$IDEN71 OPERTY. BACKFILL.SEPTIC TANKSRESEEP.PIT(S) G CESSPOOLSMITTEE r �Vl�
' VALMATIOI -. '- ROBERT A. WOOD
CIL X.0. 1!CASH SUPERVISING MECHANICAL, ENGINEER.
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