HomeMy Public PortalAbout5756 RIO HONDO AVE_Sewer__ APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIADDRENG
JOHN A. LAM$TE, County Engivaar f
OASSATC D. GRIFFIN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN FOR
CROSS ST.
LEGAL _ s
DESCRIPTION LOT NO. d� OWNER fd F _
BLOCK TRACT r ADDRESS rr
NO.OF BLDGS,
SIZE OF LOT L-a f NOW ON LOT ' Y TEL.NO 420"
USE OF ^-,
a..c.�z...-. .._..
BUILDINGS i... -• .vDA-STRICT NQ
qGROUPJ i - MAP I PRgCESSED.'by
CONTRACTOR
A ! A�
�
ADDRESS 1� CONNECTION DATA
CITY r,.� TEL.ND. STATION -- s DEPTH /
REGISTRATION NO. [] COUNTY MANHOLE REFERENCE s� a✓STATE
PER'°
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO z' >
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT 4R TYPE OF COA-mt e'TION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y• URB P.L. M.L.-TOP.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD - - -
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO, ' JOB N0.
CONNECT ADDITIONAL''BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO F=j
WORK TO HOUSE SEWER @ $1.,00 r� -
SEWER.ORDISPOR OSAL'SYSTEM HOUSE $1 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S =FEE
$ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION ✓.�r REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE fNSFECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SEWER. �s
SIGNED THIS DAIe OF 'tom , 'j 9 NEW HOUSE SEWER
d CONNECT ADDITIONAL
OWNER ORd
OWNERS AGENT - -`' + BUILDING OR WORK
SEPTIC TANK.SEEP,PIS}
ADDRESS; r ✓r' TAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL❑ 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 AND STATE OF ABANDON_HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RE5tDE7T AL PROPERTY. -
oBACKFILL SEPTIC TANKS
SIGNATURE
SEEP. PIT(S) [I CESSPOOLS LI
1�
OF PERMITTEE
Jar VALIDATION. ROBERT A.WOOD
-,, ,y. SUPERVISING MECHANICAL.ENGINEER
� � r