HomeMy Public PortalAbout5702 RIO HONDO AVE_Sewer__ FBOB 565
6A 64 2 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
jon A. I..A ADDRESS 14�- W,Z
CoI'VNWl V1. W'N'KINS' Scp*t. of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
-LEGAL
DESCRIPTION LOT NO. OWNER .10,
MAIL
BLOCK TRACT
ADDRESS
NO- 11 IL111,
SIZE OF'LOT, 'Ile NOW ON LOT CITY TEL. NO.alf7 3
USE OF
BUILDINGS DISTRICT NO. (3ROUP MAP PROCESSED BY
BK PG
-
CONTRACTOR Z- -137
ADDRESS -e CONNECTION DATA
DEPTH 5'
CITY TEL. NO.
-L F�,C NSE: LICENSE -----
STATION,
No. NSE C LA 5S MANHOLE REFERENCE LOWER
TYPE OF COU.UECTIO ENGTH FROM
NO. N I
HNG TO
OUSE SEWER CON I Y. P.L.PLM.L.TO P.L.PL
$ 5 00
PC SER
SEF JT-ICTANK,—S-E-EPAGE I'll OR P.C.NO.
L,-SLITS ANDEWOR DRAINF[ELD C .IMP.NO. JOB NO.
$I o'o C) 0
0
1 HOUSE. CONNECT NC TO - - TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM $ 3.00i-----,
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CONNECT AOD.ITION41- BLD,. ORAFFIDAVIT WAIVER CASImEIIT�RD
WORK TO HOU E SEWER 3.00
IA YER, kPO"1 —oW-ASA-N—[)ON iOUSE
SEWER OR DISPOSAL SYSTEM $ 3.00'
��rEl�A-Gr-PTT-,-f5R-ATqFTE[--D-- W—Y.OR ST.WIDENING
EXTN.,CESS P.O UL. WAN;'CLE $ 5.00
TATE ENCROACHMENT z
PERCOLATION TEST $ 5.00i PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVVNER'S PERMIT $ 21 00
AUTHORIZATION I TOTAL FEE eCONNECTION CHARGE FEE
e
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
To THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS. DAY OF --19-- — ---
OWNER OR NEW HOUSE SEWER -1
OWNERS AGE CONNECT ADDITIONAL
BUILDING OR WORK
ACDRESS--
PI
I HEREBY ACKNOWLEDGESEPTIC TANK,SEEP,- THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD T(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMS ING AND SEWERS. CESSPOOL [] DRYWELL Fl
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
L ICE NSE DAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
HE DISCONNECT PLUG AND
RESIDE IN, T
�X-�a�E DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
5Z71
SIGNATURE BACKFILL. . ..- .
OF PERMITTI L'C-IANKS 0
CESSPOOLS
"J"LIDATION
er CI%. M.O. CASH
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