HomeMy Public PortalAbout4959 ROBINHOOD AVE_Sewer__ d -z
'6A'6-42D - E808 -'° " APPLICArION FOR P MIT
* COUNTY OF LOS ANGELES EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �y
ADDRESS / /♦(i` ///✓ v
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL --
DESCRN
IPTION LOT O. OWNER -
MAIL �'*
BLOCK TRACT � � ADDRESS w�F..d" (,,,__ e —
N . OF. OF B -LOGS.
SIZE OF LOT NOW ON LOT CITY �- T.L. NO.
� DISTRICT NO. GROUP B Pa
MAP CESSED BY
9UILDINGSC.
GONTRACTOF�41'��j��� (WJE• ,/X �/ ,.7�Lr�l E'p�� j�C�' - � � •� •r �
ADDRESS,/F5;"" 7y1I C ECTION DATA
,/ STATION / DEPTH
CITY J -'TEL. NO. `' /
STATE ,yy "��!} LIC `/'_ MANHOLE REFERENCE
LICENSE NO.
NO. -DESCRIPTION OF WORK FEE TYPE OF CONNECTION - LENGTH FROM
HOUSE SEWER CONNECTING TO //. 0 Y. CURB .L, M.L.TO P.L.
PUBLIC SEWER @ $7.00 V�
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS A.ND/OR DRAINFIELD @ $10.00 CO. IMP.NO. JOB NO. ,/
HOUSE SEWERCONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. D}..
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR gFFIDAViT wAIVEN "EASEMENT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRY WELL. @ $5.00HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE O
SEWER OR DISPOSAL SYSTEM @ E3.00 STATE ENCROACHMENT W
MANHOLE Q $7.00 PERMIT NO. C•
--- - INDUSTRIAL v)
WASTE APPROVAL z
CHARGES
OWNERS PERMIT $ 31 00
AUTHORIZATION TOTAL FEE 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 DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
J _
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 1'-I
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
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 SYSTEM
C 4LIFORNIA OR THAT I AM THE LEGAL OWNER 07. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENT IA PRO ERT Y. ABANDON HOUSE SEWER
SIGNATURE y�sJ „r BACKFILL SEPTIC TANKS ❑
OF PER MfTTEE - ------ SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATIQN CK. M.O. CASH