HomeMy Public PortalAbout4958 ROBINHOOD AVE_Sewer__ ...EE3G8 I1-57
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ;
JOHN A. LAMBIE, Count. Engineer ADDRESS
CASSATT D. GRIFFIN. Sup t of Building }
_!_"CA L'TY TY�
NEAREST 4r
FOR APPLICANT TO FILL IN CROSS ST. C 414�1_7>
LEGAL - _ -
DESCRIPTION LOT NO. J OWNER
BLOCK TRACT MAIL
ADDRESS
{-, NO.OF BLDGS. - --
SIZE OF LOT `" y NOW ON LOT CITY TEL,NO,
USE OF .--
BUii�DINGS 'r`S: DISTRICT NO. f GROUP MAP
CONTRACTOR- i - J' I BK PG
ADDRESS /I IC 7� i y r -r7° CONNECTION DATA
CITY ✓ i y ,.��/ TEL.NO. STATION DEPTH
- - ,&%"
- -y -� ❑ STATE [iPPER
REGISTRATION NO.
MANHOLEREFER£NCE.. —
LOWER
NO, _ DESCRIP T t_ON OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER 0 $3.50 ------
.SEPTIC TANI(,SEEPAGE PIT OR TYPE OF C O ��ECTION LENGTH FROM
PITS AND/OR DRAINF_I-EL.D Cay $3,00 Y. C U R 6 P.L. M.L.TO P.L. _
OVERFLOW SEEPAGE PIT,DRAINFIELD
_EXT'N.,CESSPOOL,DRYWELL,MANHOLE C $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1,00 Co.TMP.NO. JOB N0,
CONNECT ADDITIONAL BLDG.OR -�- `-
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE — -
SEWER 0R DISPOSAL SYSTEM $1,00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL -
CHARGES _
OWNER'S _PERMIT $ i 1II 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE i. zl , REIMBURSEMENT FEE
1 HAVE AT THIS DATE CONTRACT WITH THE HEREIN NAMEDCON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. —
SIGNED IHS— IAAY Q —- )$,_ NEW HOUSE SEWER
OWNER OR � - CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK_
ADDRESS— SEPTIC TANK,SEEP,PIT(S) -
-- -------- — AND/OR_DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYCESSPOOL[] DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALT'R,REPAIR,SEWER OR
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT i AM -PROPERLY REGISTERED AND/OR _SEW-AGE DISPOSAL SYSTEM -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND-STATE- OF DISCONNECT PLUG AND
CALIFORNIA__OB__THAT i,AM THE LEGAL OWNER OF' THE-ABOVE ABANDON HOUSE SEWER
DESCRIBED,-RESfDENTIAL,`PP;PERTT, BACKFILL SEPTIC TANKS
0
SIGNATURE_.
� SEEP. PIT(S) ❑ CESSPOOLS
OFPERMITTE {
x VALIDATION ROBERT A. WOOD
C!(. M.0. CASH SUPERVISING MECHANICAL ENGINEER
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