HomeMy Public PortalAbout5744 RIO HONDO AVE_Sewer__ 6A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
I3tYIIII?II3G AND SAFETY DIVISION EUILDING
JOHN A. LAhSBIE, Couniy Engineer ADDRESS �z -L • Is -B,
WILLIAM A. JENSEN. Supt of Building
LOCALITY NEAR£ TEOR 1�IPPLICANT TO FILL IN � .�lDC:B'CR P ONCT NO j.. y . x //L ,,lONNER g ✓'g�....'?if.CFMAIL
131.00K TRACT '. ADDRESSNO OF BLDGS. f� ]SIZE G _OT-- ", j f NOM! ON LOT C:TY TEL. NO,
VSE c DtSTR3r..T'NO. c ROUP MAP P
BUILD N 5
m.
PG
CONTRACTOR
ADDRESS _ CONNECTION DATA - -
STATION f F QEPTH , /
CITY TEL NO.
STATEMANHOLE REFERENCE s;
REGISTRATION NO. COUNTY LOWER
NO. , GESL:WI -10 N O.F WORK FEE
TYPE OF CONN-ECTION LENGTH FROM ;
HOUSE SEWER+CONNEC'TMG TO -
r Y. CURB ,,' P.L. M,L T'^.P,L.
_£
PUBLIC SEWER @ $5.00 -__--- - - - _ -
_. - .r...
COIMP NOP / P.C.PNO.
SEPTIC JOB
--- °`YaPITS AND/OR DRAINFIELD . '
HOU SE.SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
FR VATE DISPOSAL SYSTEM f"� $i.00 � � d
_ _ _ __-_ __ asy
c.NNEC7 ADD�'CIONAL BLDG` OR — -- - AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NU !
WORK TO fiC S SEWER @ $?.00 11
--
OVERFLOW SEEPAGE IT,DRA INFI EEC
EXTN.CESSPOOL,DRYWELL.MANHOLE 55.00
_. _ .. E. NWY. OR ST.WIDE NTNG
1 ALT E'R,REPAIR OR ABANDr�ry
HOUSE i i - _-___
5 Vt'ER OR DISPOSAL SYSTEM $3.00 STATE ENCROACH MINT
_ I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
-_.__ 1,_ CHARGES
OWNERS PERMIT s z' Oo -_- _-- - —__---- --
/-`y -- CONNECTION CHARGE F£E.
AUTHORIZATION TOTAL PEE
— R'EiMBURSEM£N1'FEE
't HAVE AT PHIS DATE A CONTRACT WITH THE HEREIN NAMED CON- - _MSU SiEME --E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ---- - !- -- -- - ---'
TU THE PUSI_IC SEWER. APPROVALS DRTE TINSPE4CTOR S SIGNATURE
SIGNED.THIS DAY
OWNER OR NEW HOUSE SEWER
OWNERS AGENT—______ '-..-
CONNECT ADDITIONAL
BUILDING OR WORK
7..
SEPTIC TANK,SEEP,PIT IS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE: TO COMPLY -- ----- —.�--.--
IW1H ALL COUNT Y ORDINANCES ,AND STATE LAWS REGULATING
PLUM S'NC- AND SEWERS CESSPOOL El DRYW ELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL 5YSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO --�_.._
DVAND NEC.T. SE S AND
RESIDE lN; THE' Ak30VE' DESCRIBk'f
/ED RESIDENTIAL POPF.RTY.� AB:4NDONiia USE.SEWER u
SIGNATURE
TIC TANKS
Ae+Ai
11
OF PEftM17T'E£ _ -f -x-`-s =:.-' 1.! __ --- I�- BACKFILL
LISP'} CESSPOOLS L �
f.,--�VALIDATION ROBERT A. WOOD
I
CK. M.UCASH
SUPERVISING MECHANICAL ENGINEER
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