HomeMy Public PortalAbout4866 ROBINHOOD AVE_Sewer__ 7gA
E-663 19•S5 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING _§
JOHN A. LAi.IB1E, COUNTY ENGINEER ADDRESS
J CASSATT E). GRIFFIN, SUPT OF BUILOiNG LOCALITY
NEAREST - `--------------FO
R APPLICANT TO FILL IN CROSS ST
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PTION LO? NO.-- —,_.----- OWNER
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ACTO_ ._ CONINECTION DATAS--"' STATION_ '' "j DEPTH --
Cl7Y , � € �y..y TEL. NO.may+` MANHOLE REFERENCE
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STATE -------"— - -C�-i---------- ----
REGtSTRA'TION NO. ❑ COUNTY
NO. 11 DESCRIPTION OF WORK FEE - - ---- -- -----
--r ----- ------- - ---- ---- — ---- -- TYPE OF CONNECTIO - LEN GT'H FROM— - _I✓
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HOUSE SEWER CONNECTING 7O 5 ga--"A'9; °" .-fig" P L. it M.L.TO P.L.
i P U B L I C S EN E R chi $3.,,0___
s-' ----— ---- 9�^'�'- ------- ------._.
SEPTIC TANK.SEEPAGE PIT OR
t PIT'S AND/OR DRAINFIELD C: $3.00 _ - ------.-----.-- ------ ---------
1 OVERFLOW _ PAGE PIT DRAINFIELD - ,_-- P C. NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2.00 ' _ CO. IMP, NO 106 N0. _—
HOUSE SEWER CONNECTING TO
�. PRIVATE DISPOSAL SYSTEM itu $1,00 TRUNK PERMIT NO. ROAD PERMIT NO.
STATE ENCROACHMENT
�F PERMIT NO,
CONNnC7ADOi"iONALBLDG OR !
WORK TO NOUS_ SEWER C� $I.00
ALTER REPAIR OR ABANDON HOUSE - -__----- -._.__^--�—
SEWER OR DISPOSAL SYSTEN �' $1.00 I INDUSTRIAL
__. _. . � _ _ WASTE APPROYAi.
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PEAIvIIT -- 5 --t oo ------ ------------ -------_--
---- --- --- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
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I HAVEAT THIS DATE CONTRACT WITH THE HEREIN NAMED CON- ____APPROVALS DATE--___--__-�— ___._.IINSPECTOR'SSIGNATIIRE
TRACTOR TO CONNECT "-. VE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE 1 NEW HOUSE SE NER --� — _-
SIGNEDF CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT�:I. _ SEPTIC TANK,SEEP,PIT(S)
.ADDRESS- AND/OR DRAINF ELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION '
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL(] -DRYLdELL1]-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _ _F
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND — r
LICENSED AS REQUIRED by LCS ANGELES- COUNTY AND STATE OF !
ABANDON HOU5ESEINER
CALiFORN(A OR THATI������aM THE LEGAL GWNER OF THE ABOVE ---- --_ ._-- '- --�---------.. ..__—__,.
DESCRIBED RESIDENTIA"""""" 4PERIY _ BACKFILL SEPTIC TANKS
SIGNATURE - �(( y` y , �,./ �� SEEP.-PIT(S)LI CESS_P_O_OLS_D
OF PERMITTEE
i
)OHN A.L.AMBIE,COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF f LBG. INSPECTOR
CK. M.Q. Al
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41 J
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