HomeMy Public PortalAbout9064 RANCHO REAL RD_Sewer_1962-05-02 16A6420 APPLICATION FOR PER IT ;.
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
° r
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building
_ LOCALITY C✓' -"
FOR APPLICANT TO MIN NEAREST
CROSS ST. ..
LEGAL jJ
DESCRIPTION LOT NO. OWNER.
BLOCK 1 TRACTMAIL
e' ADDRESS _.
NO.OF BL.DGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
OF I
BUILDINGS DISTRICT NO. GROUP MAP PROCES D BY rI
BK PG T.
CONTRACTO
ADDRESS p <, CONACTION DATA,
CdTY J~ TEL.N0. ATION �:. '� 'p DEPTH
d 4g STATE MANHOLE REFERENCE t �, UPPER
REGISTRATION NO. __ COUNTY / C)
NO. 1 DESCRIPTIO OF W1DRK FEE
HOUSE SEWER CONNECTING TO 1 _
PUBLIC SEWER @ "00 - E4
-- TYPE OF CONNECTION LENGTH FROM4
y SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ 53.00
OVERFLOW SEEPAGE PIT,DRAINFIELD '.•1 }£, t; 9-
EXTN..CESSPOOL.DRY-WELL @ $2.00CL
HOUSE SEWER CONNECTING TO '
`,,✓ P.C.NO. ®
' (`y
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP,N0. JOB NO. U f'la
CONNECT ADDITIONAL BLDG.OR ^' r ✓ ' ' 1 v V
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.t
A&TE R,OR PAIR OR A SYSTEM HOUSE �� $1.00 STATE ENCROACHMENT O 1,
PERMIT N0.
INDUSTRIAL 'L
-WASTE APPROVAL
CHARGES Z
ONr EWS PERMIT' $ 2 00 CONNECTION CHARGE.FEE r
-AUTHORIZATION TOTAL FEE % - REIM13URSEMENTFEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN M'AMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROWALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS DAY OR 49— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS _ _ SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAlNFIELO
HEREBY ACKNOWLEDGE THAT 1 HAVE REVD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL C 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 ANR, STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE £GAS OW W OF )fHE ABOVE
DESCRIBED RESIDE AL RO 1.+d' BACKFILL SEPTIC TANKS
S S:P.PIT(S) CESSPOOLS
SIGNATURE 'n
OF PERM,... y'
VAIMATION ROBERT A. WOOD
cle ; r.o. nsR SUPERVISING MECHANICAL ENGINEER
��'r
rR
®° APPLICATION FOR PER IT t
2
6 A 6420 Cr
COUNTY OF LOS ANGELES SEWER--SEWAGE D I SP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN Ay LANSBIE, County En ADDRESS inoea � Y
WILLIAM A. JENSEN. ^S'up't of Building LOCALITY
NEAREST
FOR APPLICANT TO FUI IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT i MAIL
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP BK MAPPG PROCESSxo BY
CONTACTOR _
ADDRESS CONNECTION DATA '
CITY s '` TEL.NO. 'MON f DEPTH
r STATE MANHOLE REFERENCE �®UPPE
REGISTRATIONNO. i COUNTY
NO. I DESCRIPTION OF WORK FEEHOUSrtrim
f;
PUBLIC SEWER EECONNECTINC� TO 191 $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM51
PITS AND/OR DRAINFIELD $3.00 Y. CURB P.L.
OVERFLOW SEEPAGE PIT. AINFIELD �-
E7(TN.,CESSPOOL,DRYWEDRLL C 52.00 a.
HOUSE SEWER CONNECTING TO J o r" ✓" P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1,00 CO.IMP. NO. ? JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0 f cz
WORK TO HOUSE SEINER $1.00 '�
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWEROR DISPOSAL SYSTE C $1.00 PERMIT NO. U
INDUSTRIAL a.
WASTE APPROVAL th
�tfwre�
CHARGES Z
OyWNER'S PERM T CONNECTION CHARGE FEE
ArMO^''-�ATIvN TOTAL FEE � tJf� —.f' REIMBURSEMENT FEE
CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED E%DATE A CONTRACT WITH THERISTING EIN DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THISDAY OIa 19___ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCE3 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 COUN AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT f A T - G N /OF THE ABOVE
✓ BACKFILL SEPTIC TANKS
DESCRIBED RESIDEN T ❑
SIGNATURE
SE PITS ® CESSPO S
OF PERMITTE
"'VALIDATION( ROBERT A.WOOD
cK. .% M.0. CASH $UPERVISING MEC14ANICAL ENGINEER