HomeMy Public PortalAbout9216 WEDGEWOOD ST_Sewer__ 6A 6420 -`CE808 -10-71
APPLICATION FOR PE IF. tlrT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCROSS
d/
/ y
j
FOR APPLICANT TO FILL IN
.
LEGAL ttyy ----_"_--
_DESCRIPTION LOT NO. ter. OWNER
MAIL
BLOCK TRACT ADDRESS q -
O. OF BLDGS. _
SIZE OF LOT,'-,04 NOW ON LOT CITY TEL. `.
USE OF
BUILDINGS DISTRICT NO. GROUP I MAP PRO ESSED BY
SK PS
Y
CONTRACTOR
ADDRESS CONNECTION DATA
ST TION DEPTH
CITY TEL. NO.
STATE LIC ''aa,,� UPPER
LICENSE NO, CLASS MANHOIE^R.);FER ENCE
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECSyON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURBP,iL. M.L.TO P.L.
PUBLIC SEWER @ $7.00
NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. D13N,0.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT,.IJ Off. Q
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONALA&DO.`OR _ AFFIDAVIT WAIVER EASex Exi RECORD,INSTR.NO. "�.,�DAT£ u
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYW ELL. $5.00 O
ALTER HOUSE - HWY.OR ST,WIDENING ti.,w
SEWER_OR_DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT V' W
MANHOLE $7 00 PERMIT NO. -CL
-' INDUSTRIAL
WASTE APPROVAL Z
OWNERS PERMIT s a 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE = "-
1 HAVE 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 -
OWNERS AGENT "---
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS ---
I---- ----- SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALE R,REPAIR.SEWER OR
LICENSED AS REQU Ifj6D BY LOS ANGLES COUNTY AN6,STATE OF S_ AGE DISPOSAL SYSTEM
CALIFORNIA OR TH#T' I AM THE LE13AL,10 NER 0F'�AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A OVE DESCRIBE REST €NTIA PR�PERTY. ABANDON HOUSE SEWER _
SIGNATURE 7 h y
OF PERMTTT EE y BACKFILL SEPTIC TANKS E3
-- — SEEP.PIT(S) ❑. CESSPOOLS dz
VALIDATION CK, M.O. CASH
4 8 4ru:1 4:5 1 0 0 9.0:0
_ r r,