HomeMy Public PortalAbout4849 ROBINHOOD AVE_Sewer__ 16A 6420-CE808-10-71 APPLICATION FOR PER ✓
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS ( /��'
LOCALITY �.� _ �' 4.�
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. - : (..' OWNER
MAIL
BLOCK TRACT ` ADDRESS
NO. OF BLDG..
SIZE OF LOT NOW ON LOT CITY
USE OF
BUILDINGS ,.- DISTRICT.NO. GROUP MAP PROCESSED,BY
` BK p5
CONTRACTOR �i'
ADDRESS ) / R- � CONNECTION DATA
CITY " ' . TEL. NO. + STATION o._.+' - '� DEPTH
�4
STKTE '� .+y LIC y MANHOLE REFS - ;j UPPER
LICENSE NO. (,/' y� GLASS f +?
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION..i""� ^LENGT ' ROM
HOUSE SEWER CONNECTING TO � ��-Y.y Y. CURB /P.L. M.L.T P.L. R
PUBLIC SEWER 0 $7.00 LL -y`
SEPTIC TANK.SEEPAGE PIT OR P
CO.IMP.
PITS AND/OR DRAINFIELD 510.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEA EASEYENi RECORD. INSTR.NO. DATE u
WORK TO HOUSE SEWER 53.00
OVERFLOW SEEPAGE PIT,DRAINFIELD _ Dd
EXTN.,CESSPOOL.DRYWELL. @ $5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 _ STATE ENCROACHMENT W
MANHOLE - - $7.00 PERMIT NO. d
— - INDUSTRIAL h
WASTE APPROVAL Z
OWNERS PERMIT $ 3 0,0 CHARGES
AUTHORIZATION1 TOTAL FEE rr E) /} Y CONNECTION CHARGE FEE
IHAVE 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 D/TE INSPECTOR'S S 14ATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER '-1
OWNERS AGENT —
CONNECT ADDITIONAL '
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 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 ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL. OWNER OF, AND INTEND TO DISCONNECT PLUG AND y
RESIDE IN, THE ABQ DE CRI BFO R I EN��AI PROPE R'�Y. C�
S✓ '� ..� ABANDON HOUSE SEWER
SIGNATURE —-
OF PERMITTEE .�.� BACKFILL SEPTIC TANKS Cl
IS SEEP.PIT(S) --GE,SSPOOLS
VALIDATION CK. M,O. CASH
6697 JUN 2,S I C) a 10.0ON
,,I
GA642D
S JE-6633.59 APPLICATIONAPPLICATIONFOR PERMIT
&
-- .DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J.FOX.COUNTY ENGINEER ADDRESS - -
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY r �.'
FOR APPLICANT TO FILL IN NEAREST --
CROSS S
LEGAL ,y --
DESCRIFTION LOT Nry. �'�' �`
-- _ '� '�:)'Lk OWNER j -
_ F }
BLOCK TRACT 'd ..: �.'.�`v MAIL 9 _ 4 "`--. 7"
_^ ADDRESS Gr f '..s..-u..�. .
_
NO. OF BLDGS. `_ > r ✓
SIZE OF LOT yK � � NOLI ON LOT CI TY�a'', j,.�/�` ✓�,� TEL. NO
USE OF .�
BUILDINGS .� .,,y..-t,{�i �. .p''{ =�. '.:.y4 �, DISTRICT N0, i GROUP ^..� MAP
SK PG
CONTRACTOR ti ,-.- y'
ADDRESS .�, CONNECTION DATA
CITY • TEL. NO. �" STATION - DEPTH
Z'87ATE MANHOLE REFERENCE UPPER-
REGISTRATION NO. ' ❑ COUNTY
NO. _ DESCRIPTION OF WORK FEE
TYPE OF CONNECTION-� LENGTH ROM �~ _
HOLSE SEWER CONNECTING TO 1 Y
3.50 CURB --P.L. A.L. TO P L_ _
—_� PUSLIC S WER _ (d S -'--- - --•— - ---
CHOUSE SEWER CONNECTING TO
PRIVAIEERISPOSAL SYSTEM 1.'0
CGNNECT ADDITIONAL BLDG. OR f P N0.
15IRK T_O s;C JSE SEyiER 1.00! �' C0._I ti P, N0.�—_ _ N0. ---`
—L a — —— }q y=------- —
ALTLR OR r2EPAIR EXISTi NG ----_.�I R I)NK PERFRI7 NO. 4 ROF DPERMiT NO.
SE ER OR DISPOSAL SYSTEM 1.00
—J
DISCONNECT AND ABANDON-SEWER I— - — � .---- -- -... -----
F,NCJ/OR L SPCSAL SYSTEM 1.00 STATE FYCPOACHI�ENT
SEPTIC TANK, SEEPAGE PIT OR ERN iT N� _
PITS AND/ORDPAINFIE D _ 2.00 V - ,US TRI A
WASTE APPROVAL
CESSPOOL- DRYW LL y '
1 SPECIAL CONDITIONS ONLY_-! ,_2.00 _d
---'---' - CONNECTION„CHARGE FEE
AUTHORIZATION
t
VNEFI'S ^FEItr3IT� j--p� ------
OV --
AUTHO5 RATION ..__TOTAL FEE � f i�'�i REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTEIS WITH THE HEREIN NAMED CON-
TRACTOR •TO CONNECT THE ABOVE DESCRIBED EXISTING DAPPROVALS APPRO ALS � DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER --- -----
SIGNED THIS_y_, _____DAY QY"., NEW HOUSE SEWER _ -
OWNER OR 1. '. .�. CONNECT ADDITIONAL
OWNERS AGENT�S - _ �� - BUILDING OR`IORK
"t SEPTIC TANK,SEEP, FIT(S)
AND/OR_DRAI.NFIELD- --- —
I HEREBY ACKNOWLEDGE THAT 1 HAVE RBA' THIS APPLICATION' CESSPOOL Q DRYWELL
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATi.NG ALTER, RE?AlR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AK. THE LEGAL OVijiER OF THE ABOVE _ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL ERTY. BACKFILL SEPTIC TANKS C
SEEP. P
SIG=NATURE IT S) [] CESSPOOLS
_,..—
It
OF PERMIT TE r - -
WILLIAM J.FOX, CO TY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
0 5 r�911t d .a} } I I
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