HomeMy Public PortalAbout6253 RENO AVE_Sewer__ '6A 642D CE808 - 9/7$ APPLICATION FOR k;ERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
IdaLOCALITY
NEAREST
FOR APPLICANT TO FILL IN GRDSB 5T. -
LEGAL �/¢ 1�'�
DESCRIPTION LOT NO:- d`.l'_"/ OWNER– t
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�y ./ MAIL -
BLOCK _TRACT �'7F��/ ADDRESS ,
! NO. OF BLDGS.
SIZE OF LOT_ NOW ON LOT CITY �? TEL. NO.
USE OF
BUILDINGSDISTRICT NO. GRQU BK Po MAP P�ESS E:Q BY
4044-�
CONTRACTORAV
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ADDRESS ] CONNECTION DATA
J O(TATI ON DEPTH
CITTEL. NO. p
UPPER
LICENSE NO, GLASS
STATE- LIC ANHOLE REFERENCE LOWER
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER a $7.00
SEPTIC TANK SEEPAGE PIT OR c' P.C.NO.
PY TS AND/OR DRAINFIELD @ $10.00 CO�6i.M P.NO. J06 NO.
HOUSE SEWER CONNECTING TO TRUNK PE .� ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 _
CONNECT ADDITIONAL BiiIfRllR AFFIDAVIT WAIVER 1A11YEMF RtC'OP/L1.,.)„NSTR..NO. DATE
WORK TO HOUSE SEWER M., $3.00 Ly
OVERFLOW SEEPAGE PIT.DRAINFIELD 4 �
EXTN,CESSPOOL.DRYWELL. 55.00 HWY.QRST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
5EWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
MANHOLE--_-�' `-� $7.00 PERMIT NO. `4
-- INDUSTRIAL L1
WASTE APPROVAL N
CHARGES v
.E�O,�W�N*ER`S PERMIT S 3 DO-
AUTHORIZATION y e?
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 — T
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19,_. ---
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS_ _BUILDING OR WORK T,
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 [J
i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND TATE OF SEWAGE DISPOSAL SYSTEM
C ALIFC.RNI.A OR THAT I AM THE LEGA WNER OF. AN INTEND TO- DISCONNECT PLUG AND
RESIDE IN. THE AB E -RISED IDE IAL PR ERTY. ABANDON HOUSE SEWER
SIGNATURE ` BACHFfLL SEPTIC TANKS ❑
OF PER MtTTE *}� SEEP.PIT fS) ❑ CESSPOOLS r
VALIDATION CK, M.O. CASH
51,